Narrow Results

Grade 2 scapholunate advanced collapse (SLAC 2) can be treated by proximal row carpectomy with satisfactory results. However, this method is invasive and can limit function. The senior author had proposed an arthroscopic alternative with tendon interposition between the radius and proximal carpal row (arthroscopic interposition tendon arthroplasty [AITA]). However, this arthroscopic technique is technically difficult and requires a risky palmar arthroscopic portal. We report a modification of AITA, the one-loop arthroscopic radiocarpal tendon inter-position (1L-ARTI) that is simpler and needs only dorsal arthroscopic portals.

Level of Evidence: Level V (Therapeutic)

We report a patient with a severe axial–radial–ulnar (ARU) fracture dislocation of the carpus, involving multiple intermetacarpal dislocations as well as divergent carpometacarpal dislocations involving the index, long, ring and small fingers and peritrapezoid and scaphotrapezial dislocations. She also had a degloving injury involving the dorsal hand. Emergent debridement followed by open reduction and internal fixation of all injuries was performed, followed by soft tissue management. At 6-year follow-up, the patient had adequate active range of motion with the ability to make a full fist and was able to use her wrist and hand for most activities of daily living. Disabilities of the arm, shoulder and hand (DASH) score was 47.5. Michigan hand outcomes questionnaire (MHQ) score was 66.8. Mayo wrist score was 65. Patient-rated wrist evaluation (PRWE) score was 42. Severe ARU fracture dislocations of the carpus can result in adequate functional recovery on long-term follow-up.

Level of Evidence: Level V (Therapeutic)

Background: Percutaneous Kirschner wire (K-wire) fixation of hand and wrist fractures is a common trauma procedure, yet there remains little consensus on the best management of wires postoperatively. If wire’s ends are left external to the skin, it remains unknown which dressing regimen best reduces infection risk. We felt that a systematic review was required to assess the current consensus on this question within the published literature.

Methods: An electronic search was carried out across multiple databases. Abstracts were screened by two independent reviewers against inclusion criteria and, where necessary, full texts were reviewed. Nine eligible papers were identified, and data regarding type of procedure, dressing choice and infection rate was extracted.

Results: The included studies were widely heterogenous, and the standard of the evidence was, in general, poor. In most, dressing choice and infection incidence were not the primary intervention/outcome under study.

Conclusions: Based on the available literature, insufficient evidence exists to establish one dressing choice as having a lower infection rate. This highlights the need for further high-quality evidence in this area.

Level of Evidence: Level III (Therapeutic)

Wrist arthroplasty is becoming more commonplace, with various implant choices available. The Motec (Swemac Orthopaedics AB, Linköping, Sweden) cementless ball-and-socket system is being increasingly utilised and is designed for the distal component to be implanted into the third metacarpal. However, distal component failure is a recognised complication. We outline our experience with the revision of this component into the second metacarpal. This technical note is presented through our experience of two patients who underwent revision arthroplasty for the management of peri-prosthetic fracture of the third metacarpal. This technique has demonstrated a safe and viable solution to this complication, achieving good anatomical centre of rotation, function, range of movement and patient satisfaction.

Level of Evidence: Level V (Therapeutic)

Background: The coexistence of carpal tunnel syndrome (CTS) and trapeziometacarpal (TMC) osteoarthritis have been previously described. The influence of TMC osteoarthritis in the outcomes of CTS surgery is yet to be elucidated. The purpose of this study is to examine the prevalence of TMC osteoarthritis in patients who underwent open carpal tunnel release (OCTR) and to analyse the influence of osteoarthritis on the postoperative outcomes of CTS.

Methods: We retrospectively reviewed 134 procedures on 113 patients who underwent OCTR between 2002 and 2017. The presence of TMC osteoarthritis was based upon preoperative plain radiograph. For the evaluation of CTS, pre- and postoperative muscle power of abductor pollicis brevis (APB) muscle by manual muscle testing (MMT) and distal motor latency (DML) detected on the APB muscle was examined.

Results: The mean follow-up period was 11.4 months. The prevalence of radiographic TMC osteoarthritis was 40% in patients who underwent OCTR. In electrophysiological study, the mean pre- and postoperative DML showed no statistical difference regardless of the coexistence of TMC osteoarthritis. However, there was a significantly higher incidence of poorer muscle strength of the APB in patients with TMC osteoarthritis. No patients complained of TMC joint pain prior to OCTR, but four cases developed TMC joint pain during the postoperative follow-up period, all of whom had full recovery of APB muscle strength.

Conclusions: The presence of asymptomatic TMC osteoarthritis may affect the postoperative outcomes of OCTR, so preoperative evaluation of TMC osteoarthritis should be considered in patients undergoing OCTR. In addition, the symptoms of TMC osteoarthritis may worsen in some patients after CTS surgery and should be taken into consideration during the postoperative follow-up.

Level of Evidence: Level IV (Therapeutic)

We report a dorsal trans-scaphoid perilunate fracture-dislocation associated with dorsal dislocation of the thumb carpometacarpal joint in a 25-year-old man. This is a rare injury and we discuss a possible mechanism for the injury.

Level of Evidence: Level V (Therapeutic)

Background: To restore distal radioulnar joint stability following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be necessary. Post-surgery rehabilitation is prescribed to restore wrist and hand function; however, no universally accepted or definitive rehabilitation protocol currently exists. The aim of this study was to survey hand and wrist surgeons regarding their recommended postoperative rehabilitation protocols following TFCC foveal repair surgery.

Methods: Australian hand and wrist surgeons were invited to complete a descriptive survey containing 10 questions. Questions included clinical recommendations for wrist and forearm immobilisation, range of motion (ROM) exercise timeframes and surgeon experience of TFCC rupture. Descriptive statistics and between-group (TFCC rupture vs. no-rupture) comparisons (Pearson’s Chi²) were calculated.

Results: Thirty-one surgeons completed the survey. Recommendations for post-surgery immobilisation ranged from ‘not required’ to 8 weeks (mode 6 weeks). Wrist and forearm ROM commencement time ranged from ‘immediately’ to ‘later than 8 weeks’ (mode 6 weeks). The most recommended orthosis was a ‘sugar-tong’ (57%). Thirty-seven percent (37%) reported experience of post-surgery re-rupture.

Conclusions: While surgeon recommendations varied, the majority recommended 4- to 6-week timeframe for immobilisation and ROM exercise commencement. Additional clinical research is recommended to evaluate whether postoperative rehabilitation decisions influence patient outcomes.

Level of Evidence: Level V (Therapeutic)

The number of domestic animal bites is on an uptrend, but the numbers are underestimated as not all patients visit hospitals to seek treatment [Lee KJ et al. Domestic dog and cat bites: Epidemiology and analysis of 823 cases over the last 5 years. J Wound Manag Res 15 (2): 68-77, 2019]. Among all bites, bites to the extremities such as hands and fingers have a higher rate of infection than elsewhere in the body due to superficial structures and high vascularity, which can aid the rapid spread of the infection [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43 (6): 590–594, 2016]. The general perception of the public about pet animal bite is that wounds that are larger and have extensive tissue involvement are dangerous, while meager puncture wounds or scratches are harmless [Kim JWK, Kim JY, Kim UG, Kang DH, Kim DS, Kim JD. Treatment of phalangeal osteomyelitis caused by a cat bite. Clin Case Reports 9 (10): 1–10, 2021]. In contrast, a small penetrating puncture injury by a pet is often considered harmless and is not treated properly, which eventually requires surgical procedure and results in permanent functional impairment for the patient [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43(6): 590–594, 2016]. Animal bites to the extremities, particularly the hands and fingers are commonly encountered as they are the most exposed parts of the body. Such bites can result in inflammation of the tendon sheath, septic arthritis, and in some cases, osteomyelitis, depending on the depth of the bite [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43 (6): 590–594, 2016]. Dog bites usually do not reach up to bone-deep, while cat bites tend to cause deep, penetrating wounds due to their sharp needle-like teeth, which can pierce joint capsules and inoculate oral flora deeper into joint capsule and periosteum [Lee KJ et al. Domestic dog and cat bites: Epidemiology and analysis of 823 cases over the last 5 years. J Wound Manag Res 15(2): 68–77, 2019; Kim JWK, Kim JY, Kim UG, Kang DH, Kim DS, Kim JD. Treatment of phalangeal osteomyelitis caused by a cat bite. Clin Case Reports9(10): 1–10, 2021; Elcock KL, Reid J, Moncayo-Nieto OL, Rust PA. Biting the hand that feeds you: Management of human and animal bites. Injury 53(2): 227–236, 2022, https://doi.org/10.1016/j.injury.2021.11.045]. Conversely, dog bites are more destructive causing large wounds that drain freely [Lim JS, Byun JH, Min KH, Lee HK, Choi YS. Osteomyelitis following domestic animal bites to the hand: Two case reports and practical guidelines. Arch Plast Surg 43(6): 590–594, 2016]. This is one of the most important reasons why cat bites are more harmful than dog bites. Pasteurella multocida, a small Gram-negative coccobacillus, is an oral commensal in many domestic animals, particularly dogs (isolated in 50–60% of cultures) and cats (isolated in 70–90% of cultures) harbor a higher proportionate of this organism in their oral cavity [Chodakewitz J, Bia FJ. Septic arthritis and osteomyelitis from a cat bite. Yale J Biol Med 61(6): 513–518, 1988]. Human infections with P. multocida are commonly encountered following animal bites or scratches [Kim JWK, Kim JY, Kim UG, Kang DH, Kim DS, Kim JD. Treatment of phalangeal osteomyelitis caused by a cat bite. Clin Case Reports 9(10): 1–10, 2021]. However, these can also occur in the absence of trauma in cases where the animal’s secretions come in contact with a wound or mucous membrane of an individual [Elcock KL, Reid J, Moncayo-Nieto OL, Rust PA. Biting the hand that feeds you: Management of human and animal bites. Injury 53(2): 227–236, 2022, https://doi.org/10.1016/j.injury.2021.11.045; Chodakewitz J, Bia FJ. Septic arthritis and osteomyelitis from a cat bite. Yale J Biol Med 61(6): 513–518, 1988]. We present a case report of a child with a pet cat bite to the right hand, leading to osteomyelitis of the trapezoid bone due to negligence.

Background: Perilunate fracture–dislocations are frequently associated with a high risk of developing post-traumatic arthritis. Current studies indicate that during mid-term follow-ups, radiological signs of arthritis do not appear to correspond with functional score. The aim of this study was to assess the occurrence of posttraumatic arthritis and the wrist function after perilunate dislocations (PLD) and fracture dislocations at a mid-term follow-up of 7 years.

Methods: We report the clinical and radiological outcomes of 17 wrists treated for PLD or fracture–dislocation by open reduction and internal fixation through a dorsal approach with dorsal ligament repair. Functional outcomes were evaluated using the short version of the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), the Patient-Rated Wrist Evaluation questionnaire (PRWE) and the Mayo Wrist Score (MWS). Results of radiographs were assessed using the Herzberg Radiological Scoring Chart.

Results: The MWS showed five excellent, five good, five fair and two poor results with an average score of 81%. Radiological analysis using the Herzberg classification revealed midcarpal and/or radiocarpal arthritis in 65% of cases, lunate collapse in 59% and an increase in the mean ulnar translocation ratio in 53% of the cases. Complications included one case of lunate osteonecrosis and one case of stage 3 scapholunate advanced collapse that required revision surgery.

Conclusions: Although the clinical and functional outcomes are favourable at mid-term follow-up, radiological evaluation shows a progression towards osteoarthritis (OA). Further research is warranted to refine treatment strategies and investigate factors influencing the development of OA.

Level of Evidence: Level IV (Therapeutic)

Perilunate dislocations and perilunate fracture-dislocations are high-energy wrist injuries, characterized by a spectrum of bony and ligamentous damage. Clinical presentation often includes decreased range of motion, swelling and pain, and a palpable wrist deformity, while radiographic evaluation of the wrist may reveal abnormal radiocarpal and intercarpal collinearity and bony insult. This particular trauma may be difficult to detect due to nonspecific clinic presentation and subtle imaging findings, and can be missed in up to 25% of initial evaluations. Prompt recognition is essential for optimal patient outcomes, as the majority of patients are young adults and thus duration of disability is significant.

Background: Pneumatic tourniquet is an effective tool to achieve hemostatic control of the surgical field in upper extremity (UE) operations. Elevated pressures have been associated with adverse effects despite various methods of pressure determination. We aim to demonstrate the usage of reduced tourniquet pressures and examine factors associated with achieving reduced pressures.

Methods: A prospective study was conducted (2016–2018) at a Level 1 Trauma Center and an Outpatient Surgical Center, totaling 226 operations, involving a reduction of cuff pressures over time from a standard baseline of limb occlusion pressure for UE operations.

Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < 0.05). 4.5% of cases resulted in breakthrough bleeding, but did not reliably occur with any pressure thresholds, patient demographics, or operative factors (p > 0.05, for all).

Conclusions: Reduced tourniquet pressures can mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require a tourniquet.

Background: Partial wrist arthrodesis (PWA) is a salvage procedure used in advanced wrist arthritis and has traditionally been performed via an open dorsal approach. In recent years, surgeons have moved towards arthroscopic fusions to minimise soft tissue damage and preserve vascular supply, increase union rates and hasten recovery. The purpose of this study is to synthesise the current literature on the outcomes of arthroscopic PWA.

Methods: A systematic review was performed to survey the literature regarding outcomes of PWA. English language studies that reported original data and commented on at least one postoperative measure of function were eligible for inclusion. Data collected included patient demographics, operation time and technique, complications and postoperative patient outcomes in the form of patient-rated surveys, grip strength, range of motion and the pain visual analogue scale (VAS).

Results: Twelve studies were eligible for inclusion, with a total of 191 patients. 94% of patients achieved union, with a mean time to fusion of 12.5 weeks. VAS, Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Wrist scores were significantly improved after the procedure, and complication rates were comparable to open procedures. Range of motion varied greatly across studies, due to heterogeneity in carpal intervals fused.

Conclusions: Arthroscopic PWA is a safe and effective procedure in the treatment of advanced arthritis of the wrist. Further comparative studies would be useful in assessing benefits of arthroscopic arthrodesis over an open approach.

Level of Evidence: Level III (Therapeutic)

The wrist and thumb postures adopted during the use of three different types of computer mouse (mini mouse; standard mouse; MouseMan) to perform eight standardized tasks were evaluated. Thirty elementary students between seven to twelve years of age were studied using a magnetic tracking system. The peak value and angular range of motion of the wrist and thumb extension/flexion and radial/ulnar deviation were measured during performing 8 standard tasks. There were statistically significant larger values in the standard mice with regard to extreme wrist extension. Angular range of wrist extension observed for the standard mice were also much higher than the mini mouse and MouseMan. There were statistically significant larger values in the MouseMan with regard to extreme wrist ulnar deviation, and an average decrease in extreme thumb flexion and angular range of thumb flexion. The results from the questionnaire showed that most elementary students preferred to use the standard mouse (40%) next was the MouseMan (37%); and the last the mini mouse (23%). The recommendation of mouse types based on the hand length for elementary students was not statistically significant in our study.

Background: The Motec cementless modular metal-on-metal ball-and-socket wrist arthroplasty is an implant with promising intermediate results. An alternative to primary wrist fusion, total wrist arthroplasty is an option for active patients, who wish to retain their wrist function. It is indicated in cases of degenerative osteoarthritis, post-traumatic arthritis and rheumatoid (inflammatory) arthritis.

Methods: A prospective review of patient demographics, pre and post-operative Disabilities of the Arm Shoulder and Hand (DASH), MAYO scores, range of movements and grip strengths. All complications in follow up were recorded across the 4 year period.

Results: 25 implants on 23 patients over 5.5 years, mean age 61; 8 females and 15 male. 10 patients with SLAC, 3 SNAC, 5 inflammatory and 7 patients with generalized osteoarthritis. The patients showed significant improvements of MAYO and DASH scores post-operatively, as well as the flexion/extension arc and grip strengths. There was just one case of implant loosening- the radial screw after a wound infection, which was revised with a longer screw. Two implants were converted to Motec fusion due to pain. One implant was dislocated and relocated. The remaining patients have had good wrist function. Only 6 patients were unable to return to work.

Conclusions: Similar to published studies, this series shows the Motec implant to be a good motion preserving alternative to total wrist fusion.

Background: Metaphyseal core decompression of the distal radius (MCD) is clinically effective in early lunate necrosis without changing individual wrist mechanics. Its concept is based on the induction of physiologic mechanisms known as physiologic fracture healing response. However, this biological concept does not yet have its place in the historically developed mechanical concepts about Kienböck’s disease and requires more detailed clarifications to understand when a change of individual wrist mechanics might be unnecessary.

Methods: Thirteen consecutive cases, Lichtman stage I (n = 1) or II (n = 12), confirmed by conventional MRI, were treated by MCD. Time off work, changes in magnetic resonance imaging of the lunate, as well as clinical outcome using modified Mayo wrist score were evaluated at final follow-up.

Results: Return to work was at six (1–10) weeks after surgery. MRI controls at short-term generally demonstrated stop of progression and signs of bone healing. Independently from ulna variance complete signal normalization was observed in six and a distinct, yet incomplete decrease of lunate bone marrow edema and zones of fat necrosis was confirmed in further six cases after a mean of 21 (13–51) weeks. One patient had radiographic controls only, stating normal healing at 56 months. After a mean follow-up of 37 (12–70) months the clinical outcomes were excellent in eleven and good in two cases (mean 95% in modified Mayo wrist score).

Conclusions: In stage I and II lunate necrosis MCD stops disease progression, it improves clinical symptoms and induces normalization of lunate bone signal alterations in MRI. Findings suggest that stage I and II lunate necrosis can be effectively treated without alterations of individual wrist mechanics. Future studies are necessary to readjust common concepts regarding Kienböck’s disease, especially focusing on conservative therapy.

Background: In patients with perilunate injuries (PLI) with multiple ligamentous and bony injuries involving the proximal carpal row, open reduction and internal fixation (ORIF) can be difficult and lead to poor functional outcomes. Proximal row carpectomy (PRC) is an alternative procedure that has been used for severely comminuted fractures. The aim of our study is to evaluate the long-term functional outcome (minimum 5 years) of patients that underwent an emergency PRC for PLI.

Methods: We conducted a retrospective study of patients who underwent PRC at our centre between 2001 and 2016. Only patients with follow-up data of more than 5 years were included in the study. We evaluated range of motion, grip strength, Mayo Modified Wrist Score (MMWS) and Quick Disabilities of Arm, Shoulder and Hand (Quick-DASH). Radiographic analyses were performed to assess the presence of radiocarpal osteoarthritis and the space between the radius and capitate.

Results: Thirteen patients were included, with an average follow-up of 78.07 months (6.5 years). The MMWS was 65 points (four excellent and good, four fair and five poor results) and the Quick-DASH score was 30 points. X-ray analysis reported only 15.3% of patients with radiocarpal arthrosis and an average radio-capitate joint space of 1.92 mm.

Conclusions: The outcomes of PRC in the management of PLI are comparable to the results reported in literature for conventional ORIF. PRC is a simpler procedure that minimises the need for re-intervention.

Level of Evidence: Level IV (Therapeutic)

Background: Proprioception and sensorimotor input are used to treat neurological and joint injuries. Following distal radius fractures (DRF) there is a temporary loss of proprioception that should be addressed. We created a protocol for evaluation, and a treatment plan following wrist surgery that is based on proprioceptive and sensorimotor input. We describe a series of patients undergoing surgery for DRF that were evaluated and treated with these protocols.

Methods: Both evaluation and treatment protocols included comprehensive sensorimotor procedures performed with eyes open and closed. These included Semmes- Weinstein, static and moving 2-point discrimination, vibration, temperature testing, Moberg pick-up- test, stereognosis and proprioception.

Results: A series of twelve patients was evaluated and treated with the protocol following surgical treatment for DRF. Patients demonstrated significant sensorimotor deficits, which improved utilizing the comprehensive sensorimotor treatment protocol.

Conclusions: Further study is necessary to validate the results of this pilot series. Use of proprioception and sensorimotor input may improve outcomes of rehabilitation following DRF.

Background: To compare the efficacy of intra-articular injection (IA) with 10 mg and 20 mg triamcinolone for treatment of rheumatoid arthritis (RA) of the wrist joint.

Methods: We enrolled 20 patients with swelling and pain in wrist due to RA in the present prospective, randomized, pilot study. Patients were randomly assigned in a 1:1 ratio to either the 20 mg or 10 mg group, and received IA of the appropriate dose of triamcinolone. Efficacy was assessed by recording Numerical Rating Scale (NRS) for pain and improvement in power doppler (PD) scale score at weeks 1, 4, and 12 of treatment compared with baseline. The shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) was recorded at baseline and week 12.

Results: The NRS was found to be significantly improved at weeks 4 (p = 0.006) and 12 (p = 0.036) among the total study population. Neither the change in NRS nor the improvement PD scale score from baseline were significantly different between the two groups at any week (NRS: week 1, p = 0.617; week 4, p = 0.727; and week 12, p = 0.878; PD scale score: week 1, p = 0.370; week 4, p = 1.000; and week 12, p = 0.179). Among the entire study population, the QuickDASH was not significantly improved at week 12 nor was the change from baseline significantly different between the two groups at week 12 (p = 0.592).

Conclusions: IA of triamcinolone was effective for pain relief in context of RA in the wrist joint. However, in terms of NRS, improvement of PD scale score, and QuickDASH score, the efficacies of 10 mg and 20 mg triamcinolone were not significantly different. Thus, IA of 10 mg triamcinolone may be sufficient for the treatment of RA in the wrist joint.

Scaphoid lunate advanced collapse (SLAC) is the most frequently encountered cause of wrist osteoarthritis. Proximal row carpectomy (PRC) and four-orner arthrodesis (4CA) are the two main surgical options to address it. Three three-corner arthrodesis (3CA) was introduced in 1997 as an alternative to PRC and 4CA. It is a motion preserving midcarpal arthrodesis easier to perform than 4CA, for which the literature has documented satisfactory outcomes and low complication rates. We report a case of a SLAC wrist treated with 3CA complicated by postoperative osteonecrosis of the lunate. To our knowledge, this complication has not been previously reported. Our patient developed osteonecrosis of the lunate 1 year after 3CA despite a good consolidation of the arthrodesis. In this case study, we discuss reasons this may have occurred, the aetiology of which is likely multifactorial. We are reporting this case to inform surgeons of this potential complication after 3CA.

Level of Evidence: Level V (Therapeutic)

We demonstrate various patterns of traumatic triangular fibrocartilage complex (TFCC) tears including some atypical that cannot be categorized under Palmer's classification. TFCC traumatic tears in 173 wrists were examined arthroscopically or macroscopically and divided into disk tears (subdivided into four types: slit tear, flap tear, horizontal tear and tear within the distal radioulnar joint) and peripheral tears (subdivided into six types: ulnocarpal ligament tear, dorsal tear, radial tear, ulnar styloid tear, foveal tear and distal radioulnar ligament tear). Combinations of these types were found in 32 wrists. Wrist arthroscopy revealed various traumatic TFCC tears that do not come under Palmer's classification; therefore establishment of a new classification for traumatic TFCC tears seems to be warranted.