Palmar Fibromatosis, Updated Review With Relationship to the A1 Pulley, Trigger Finger, and Presence of the Sonographic Comb Sign.

OBJECTIVES: Updated retrospective review of the sonographic appearance of palmar fibromatosis (PF) with evaluation of the utility of the Comb Sign previously described in plantar fibromas. Additional evaluation was conducted on the location relative to the flexor tendon, anatomic proximity of palmar fibromas to the A1 pulley and evaluate any potential association with trigger finger. METHODS: Medical record and imaging review was performed from 2017 to 2023, for patients with a new onset ultrasound or clinical diagnosis of PF. Clinical associations and imaging morphology were reviewed including presence of the Comb Sign, fibroma association with the A1 pulley, and fibroma association with trigger finger. RESULTS: Exactly 87 total fibromas in 53 patients were evaluated. The Comb Sign was present in 39% of fibromas, usually seen in transverse plane, more prevalent in multifocal disease and larger fibromas. Most (72%) palmar fibromas were within 1 cm of, contacted, or covered the A1 pulley (P < .001). Lateral extension beyond the flexor tendon axis can be seen (44%). Trigger finger and tenosynovitis were rare. However, volume and SI dimension of fibromas were associated with tenosynovitis (P < .0001) and all nine patients with concomitant trigger finger had fibromas within 1 cm from the A1 pulley. CONCLUSIONS: The Comb Sign can aid in sonographic diagnosis of PF. Lateral extension of fibromas can occur. Most palmar fibromas have a significant intimate association with the A1 pulley, and presence of trigger finger with adjacent palmar fibroma can exist and is important for hand surgeons to know preoperatively.

Reliability of Wrist Arthroscopy in the Diagnosis and Treatment of Triangular Fibrocartilage Complex Tears.

PURPOSE: Wrist arthroscopy is considered the gold standard for diagnosis of intra-articular wrist conditions including triangular fibrocartilage complex (TFCC) tears; however, the ability to reliably diagnose TFCC pathology during wrist arthroscopy is unclear. The purpose of this study was to assess the reliability of the diagnosis of TFCC tears on wrist arthroscopy videos. METHODS: Five hand surgeons reviewed 43 cases on a secure web-based platform at two time points separated by 4-6 weeks. Each case included a deidentified clinical vignette and wrist radiographs with ulnar variance measurements and an arthroscopy video of ulnar wrist pathology, averaging 42 seconds. Surgeons were queried on the presence of TFCC tear and Palmer and Atzei classifications. Interobserver/intraobserver reliabilities were determined using kappa coefficients. RESULTS: The interobserver reliability regarding the presence/absence of TFCC tear was fair-good, with kappa coefficients of 0.596 in the first round of case review and 0.708 in the second round. The overall intraobserver reliability for the presence/absence of TFCC tear was also fair-good, with a kappa coefficient of 0.567. For cases with central TFCC tears, the interobserver reliability regarding the presence of TFCC tear was perfect, with a kappa coefficient of 1.0. When central tears were excluded, the kappa coefficients decreased to 0.322 and 0.368 in each round. The interobserver reliability for the Palmer and Atzei classifications was low, with kappa coefficients of 0.220 and 0.121 in the first round and 0.222 and 0.123 in the second round. CONCLUSIONS: Experienced wrist arthroscopy surgeons demonstrated fair-good interobserver reliability for the diagnosis of TFCC tear on wrist arthroscopy. However, when central TFCC tears were excluded, interobserver reliability was poor. These findings demonstrate a need for a focus on education for wrist arthroscopy anatomy. CLINICAL RELEVANCE: This investigation demonstrated poor agreement in surgeon identification and classification of TFCC tears, aside from central TFCC tears. The low reliability has a direct bearing on treatment considerations for TFCC tears.

Synthetic Tape Augmentation for Thumb Carpometacarpal Joint Instability: Surgical Technique.

Background Dorsal thumb carpometacarpal (CMC) instability can occur after traumatic injury and can lead to persistent pain and dysfunction of the hand. We present a case report of a joint-sparing technique for recurrent thumb CMC instability after failed Eaton-Littler procedure. Case Description We describe a technique to repair the dorsal radial ligament and augment the repair with dorsal synthetic tape. To illustrate this technique, we describe a patient who underwent the synthetic tape augmentation procedure for recurrent thumb CMC instability after a failed Eaton-Littler reconstruction. Preoperative and postoperative grip strength, appositional pinch, oppositional pinch, radial abduction, palmar abduction, and postoperative quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) were recorded. At final follow-up 18 months after surgery, the patient had returned to manual work without any functional sequelae. The thumb CMC joint was stable and his postoperative QuickDASH score was 15.9. Literature Review Thumb CMC instability has traditionally been treated with Eaton-Littler ligament reconstruction which uses a slip of flexor carpi radialis tendon to reconstruct the deficient ligaments. More recently, the importance of the dorsal radial ligament in joint stability has been recognized and new procedures have been described to reconstruct the dorsal radial ligament. To our knowledge, synthetic tape augmentation for thumb CMC instability has not yet been described for this pathology. Clinical Relevance Synthetic tape augmentation for dorsal thumb CMC instability may be considered in the management of dorsal thumb CMC joint instability.

Magnetic Resonance Imaging Assessment of Ulnar Wrist Pain: A Practical Guide for Surgeons.

Ulnar-sided wrist pain is a challenging clinical scenario due to multiple overlapping pathologies and involved anatomic structures. Advanced imaging such as magnetic resonance imaging can be used as an effective diagnostic adjunct if interpreted correctly. In this article, clinically relevant structures and radiographic correlates of the ulnar wrist are discussed and a corresponding systematic approach to reviewing magnetic resonance imaging is presented.

Morphology of the scaphotrapeziotrapezoid joint: A multi-domain statistical shape modeling approach.

The scaphotrapeziotrapezoid (STT) joint is involved in load transmission between the wrist and thumb. A quantitative description of baseline STT joint morphometrics is needed to capture the variation of normal anatomy as well as to guide staging of osteoarthritis. Statistical shape modeling (SSM) techniques quantify variations in three-dimensional shapes and relative positions. The objectives of this study are to describe the morphology of the STT joint using a multi-domain SSM. We asked: (1) What are the dominant modes of variation that impact bone and articulation morphology at the STT joint, and (2) what are the morphometrics of SSM-generated STT joints? Thirty adult participants were recruited to a computed tomography study of normal wrist imaging and biomechanics. Segmentations of the carpus were converted to three-dimensional triangular surface meshes. A multi-domain, particle-based entropy system SSM was used to quantify variation in carpal bone shape and position as well as articulation morphology. Articular surface areas and interosseous proximity distributions were calculated between mesh vertex pairs on adjacent bones within distance (2.0 mm) and surface-normal angular (35°) thresholds. In the SSM, the first five modes of variation captured 76.2% of shape variation and contributed to factors such as bone scale, articular geometries, and carpal tilt. Median interosseous proximities-a proxy for joint space-were 1.39 mm (scaphotrapezium), 1.42 mm (scaphotrapezoid), and 0.61 mm (trapeziotrapezoid). This study quantifies morphological and articular variations at the STT joint, presenting a range of normative anatomy. The range of estimated interosseous proximities may guide interpretation of imaging-derived STT joint space.

Inflammatory Markers Involved in the Pathogenesis of Dupuytren's Contracture.

Dupuytren's disease is a common fibroproliferative disease that can result in debilitating hand deformities. Partial correction and return of deformity are common with surgical or clinical treatments at present. While current treatments are limited to local procedures for relatively late effects of the disease, the pathophysiology of this connective tissue disorder is associated with both local and systemic processes (e.g., fibrosis, inflammation). Hence, a better understanding of the systemic circulation of Dupuytren related cytokines and growth factors may provide important insights into disease progression. In addition, systemic biomarker analysis could yield new concepts for treatments of Dupuytren that attenuate circulatory factors (e.g., anti-inflammatory agents, neutralizing antibodies). Progress in the development of any disease modifying biologic treatment for Dupuytren has been hampered by the lack of clinically useful biomarkers. The characterization of nonsurgical Dupuytren biomarkers will permit disease staging from diagnostic and prognostic perspectives, as well as allows evaluation of biologic responses to treatment. Identification of such markers may transcend their use in Dupuytren treatment, because fibrotic biological processes fundamental to Dupuytren are relevant to fibrosis in many other connective tissues and organs with collagen-based tissue compartments. There is a wide range of potential Dupuytren biomarker categories that could be informative, including disease determinants linked to genetics, collagen metabolism, as well as immunity and inflammation (e.g., cytokines, chemokines). This narrative review provides a broad overview of previous studies and emphasizes the importance of inflammatory mediators as candidate circulating biomarkers for monitoring Dupuytren's disease.

Etiology and Diagnostic Challenges of Ulnar Wrist Pain in Pediatric and Adolescent Patients.

PURPOSE: Diagnosing the cause of ulnar-sided wrist pain can be difficult in the pediatric and adolescent age group. While frequently used, the diagnostic accuracy of magnetic resonance image (MRI), as compared with intraoperative arthroscopic findings, is not well-described in this population. This study aimed to determine concordance rates between magnetic resonance and arthroscopic findings depending on the specific ulnar wrist pathology. METHODS: A retrospective review was performed to identify pediatric and adolescent patients who underwent operative treatment of ulnar wrist pain between 2004 and 2021. Patients were included in the analysis if they were <18 years of age, complained of ulnar-sided wrist pain, underwent MRI of the affected wrist with an available report interpreted by a consultant radiologist, and had a diagnostic arthroscopy procedure within one year of imaging. Ulnar pathologies analyzed included triangular fibrocartilage (TFCC) tears, ulnotriquetral (UT) ligament tears, lunotriquetral ligament abnormalities, and ulnocarpal impaction. RESULTS: A total of 40 patients with a mean age of 15-years-old (range 11 to 17) were included in the analysis. Twenty-four were female, and approximately half had their dominant extremity affected. Most had a history of antecedent trauma (n = 34, 85%), but only 15/40 (38%) had a history of fracture. The mean duration of symptoms prior to presentation was six months (standard deviation, 7). The most common etiologies were Palmer 1B TFCC tears (n = 27, 68%) followed by UT split tears (n = 11, 28%). MRI overall demonstrated high specificity (82% to 94%), but low sensitivity (14% to 71%) for ulnar-sided wrist conditions. Accuracy varied between 70% and 83% depending on the specific injury. CONCLUSION: While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. Surgeons should have a high degree of suspicion for TFCC-related pathology in the setting of positive provocative clinical examination despite negative MRI findings in young patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IIb.

Wrist Motion Assessment in Tennis Players using Three-Dimensional Motion Capture and Dynamic Electromyography.

Background Tennis players often present with ulnar-sided wrist pain, which may reflect repetitive stress and/or faulty mechanics. There is a role for investigating the biomechanics of tennis strokes and how they may relate to wrist pathology. The purpose of this study was to investigate whether three-dimensional motion capture technology and dynamic electromyography (EMG), when used to study groundstrokes in elite junior tennis players, reveals patterns of upper extremity motion that may correlate with the development of clinically relevant pathology. Case Description Three-dimensional kinematic and EMG data were collected from two United States Tennis Association-ranked adolescent tennis players during groundstrokes. There were several observed differences in the two players' degree and timing of pronation/supination, ulnar/radial deviation, and flexion/extension during their strokes. Clinical Significance Advanced motion capture technology facilitates a nuanced understanding of complex movements involved in groundstroke production. This methodology may be useful for identifying athletes who are at risk for injury and guiding rehabilitation for players experiencing pain. Level of Evidence IV.

Detection of scapholunate interosseous ligament injury using dynamic computed tomography-derived arthrokinematics: A prospective clinical trial.

Scapholunate interosseous ligament injuries are a major cause of wrist instability and can be difficult to diagnose radiographically. To improve early diagnosis of scapholunate ligament injuries, we compared injury detection between bilateral routine clinical radiographs, static CT, and dynamic four-dimensional CT (4DCT) during wrist flexion-extension and radioulnar deviation. Participants with unilateral scapholunate ligament injuries were recruited to a prospective clinical trial investigating the diagnostic utility of 4DCT imaging for ligamentous wrist injury. Twenty-one participants underwent arthroscopic surgery to confirm scapholunate ligament injury. Arthrokinematics, defined as distributions of interosseous proximities across radioscaphoid and scapholunate articular surfaces at different positions within the motion cycle, were used as CT-derived biomarkers. Preoperative radiographs, static CT, and extrema of 4DCT were compared between uninjured and injured wrists using Wilcoxon signed rank or Kolmogorov-Smirnov tests. Median interosseous proximities at the scapholunate interval were significantly greater in the injured versus the uninjured wrists at static-neutral and maximum flexion, extension, radial deviation, and ulnar deviation. Mean cumulative distribution functions at the radioscaphoid joint were not significantly different between wrists but were significantly shifted at the scapholunate interval towards increased interosseous proximities in injured versus uninjured wrists in all positions. Median and cumulative distribution scapholunate proximities from static-neutral and 4DCT-derived extrema reflect injury status.

Dynamic Computed Tomography of the Distal Radioulnar Joint Versus Magnetic Resonance Imaging in Detecting Foveal Tears of the Triangular Fibrocartilage Complex.

BACKGROUND: Diagnosis of foveal triangular fibrocartilage complex (TFCC) tears remains difficult. The purpose of this study was to evaluate whether dynamic computed tomography (CT) of the distal radioulnar joint (DRUJ) has a higher sensitivity in detecting foveal tears of the TFCC when compared with magnetic resonance imaging (MRI). METHODS: A database query identified all patients above the age of 18 years with suspected foveal TFCC injuries who underwent bilateral dynamic CT imaging of the DRUJ, static 3T MRI, and subsequent wrist arthroscopy. All patients had evidence of foveal tenderness on clinical examination. The imaging results were validated with wrist arthroscopy. RESULTS: Twelve patients with a mean age of 31 years (range, 18-53 years) were identified. Eight patients were diagnosed with a complete foveal detachment of the TFCC on wrist arthroscopy. Of the 8 patients with a foveal tear on DRUJ arthroscopy, only 3 had a preoperative physical examination suggestive of DRUJ instability. Magnetic resonance imaging identified foveal injuries in 4 of these 8 patients (sensitivity, 50%), and 3 of these were identified as only partial tears. Dynamic CT identified instability of DRUJ in 6 of 8 patients (sensitivity, 75%). Seven of 8 patients had imaging findings suggestive of a foveal tear when including either MRI or CT imaging (sensitivity, 88%). Of the 4 patients with an intact foveal attachment on arthroscopy, 3 (specificity, 75%) had a stable DRUJ on CT and all 4 (specificity, 100%) had an intact foveal attachment on MRI. CONCLUSION: Sixty-two percent of patients with foveal tears on arthroscopy have a stable DRUJ on clinical examination. When combining MRI and dynamic CT imaging of the DRUJ, the sensitivity of detecting a foveal TFCC tear approaches 88% compared with a gold standard of wrist arthroscopy.

Biomechanical Stability of Diaphyseal Ulnar Shaft Fractures and Ulnar Shortening Osteotomies After Fixation.

BACKGROUND: To determine the amount of micromotion during forearm rotation after diaphyseal ulnar shaft fracture or osteotomy. METHODS: This was a biomechanical study using 7 paired-matched cadavers. The upper extremity was mounted in a custom rig and the forearm brought through full pronation and supination. A Hall effect sensor was placed at the fracture ends to measure micromotion for all tested conditions. There were 4 conditions tested: (1) intact ulnar shaft with plate to act as a control; (2) transverse fracture/osteotomy without stabilization; (3) fracture/osteotomy with cortical apposition stabilized with plate fixation; and (4) 50% comminuted fracture stabilized with plate. RESULTS: There was a significantly greater amount of fracture site motion in the fracture/osteotomy model without stabilization compared with all other tested conditions (P < .001, .0001, .0003, respectively). The fracture/osteotomy site with cortical apposition and the comminuted fracture models showed no statistically significant differences in the amount of micromotion compared with each another (P = .952) or compared with the intact ulnar shaft (P = .997, .889, respectively). CONCLUSIONS: There was no significant difference in the amount of motion between an intact ulnar shaft, an ulnar shaft fracture with cortical apposition stabilized with a plate, and a plated comminuted fracture. These findings may help surgeons decide on their type of postoperative immobilization in the setting of isolated ulnar shaft fractures or ulnar shaft osteotomies stabilized with plate fixation.

Validation of the Clenched Fist View in Detecting Scapholunate Ligamentous Injury.

BACKGROUND: The purpose of this study was to determine the predictive value of the clenched fist stress views in identifying scapholunate ligament injuries. METHODS: An institutional review board-approved retrospective chart review was conducted of adult patients who underwent diagnostic arthroscopy with a ligamentous wrist injury from 2015 to 2020. Standard posteroanterior, lateral, and clenched fist stress radiographs were reviewed and scapholunate ligament gaps recorded. RESULTS: A total of 124 patients were included, of which 88 had normal standard radiographs and clenched fist radiographs. The positive predictive value of the clenched fist view was 69%, whereas the negative predictive value was 58%. The sensitivity of the clenched fist view was 40%, while the specificity was 82%. Of those patients with a negative clenched fist view, 42% were found to have an arthroscopic Geissler classification of 3 or higher scapholunate ligament injury. CONCLUSIONS: Despite the emphasis on stress radiographic views, a normal stress clenched fist view does not preclude arthroscopic findings of a Geissler class 3 or greater injury in symptomatic patients. The sensitivity of a clenched fist view is only 40%. These findings question the utility of stress radiographs when assessing for scapholunate ligament injuries.

Volar Wrist Arthroscopy Portals Using the NanoScope Are Safer than Traditional Arthroscopy.

BACKGROUND: The NanoScope, given its smaller size, may be further from critical structures when establishing volar wrist arthroscopy portals compared to the traditional 2.7-mm arthroscope. METHODS: Ten fresh-frozen latex-injected cadaver specimens were utilized. The volar radial (VR) and volar ulnar (VU) portals were created using an inside-out approach. The volar radial midcarpal (VR-MC) and volar ulnar midcarpal (VU-MC) portals were created using an inside-out approach. The arm was then dissected under 3.5-mm loupe magnification. Digital calipers were used to measure the distance between the portals and the surrounding anatomic structures by two fellowship-trained hand surgeons. RESULTS: The median nerve was on average 1.6, 7.2, 1.8, and 5.6 mm away from the trochar for the VR, VU, VR-MC, and VU-MC, respectively. The median nerve fascia was pierced by the VR portal in one specimen. The radial artery, ulnar artery, and ulnar nerve were not pierced in any specimen. Compared to historical controls, for the VR-MC portal, the NanoScope was further from all critical structures, aside from the radial artery, and did not pierce any neurovascular structures. For the VU-MC portal, the NanoScope was further from the ulnar artery and median nerve and did not pierce any neurovascular structures. CONCLUSION: In developing volar portals, after placing the cannula through the volar capsule from an inside-out approach, we recommend making a volar incision and dissecting the local anatomic structures to guard against injury. Compared to historical controls, the NanoScope was typically further from neurovascular structures.

Investigation Into the Effects of Intra-Articular Steroid on Post-Traumatic Osteoarthritis in Distal Radius Fractures: A Randomized Controlled Pilot Study.

PURPOSE: The aim of this prospective, randomized, controlled, double-blinded pilot study was to determine the rates of post-traumatic osteoarthritis and assess joint space width in the presence or absence of a single intra-articular injection of corticosteroid after an acute, intra-articular distal radius fracture (DRF). METHODS: Forty patients received a single, intra-articular, radiocarpal joint injection of 4 mg of dexamethasone (DEX) (n = 19) or normal saline placebo (n = 21) within 2 weeks of a surgically or nonsurgically treated intra-articular DRF. The primary outcome measure was minimum radiocarpal joint space width (mJSW) on noncontrast computed tomography scans at 2 years postinjection. Secondary outcomes were obtained at 3 months, 6 months, 1 year, and 2 years postinjection and included Disabilities of the Arm, Shoulder, and Hand; Michigan Hand Questionnaire; Patient-Rated Wrist Evaluation; wrist range of motion; and grip strength. RESULTS: At 2-year follow-up, there was no difference in mean mJSW between the DEX group (2.2 mm; standard deviation, 0.6; range, 1.4-3.2) and the placebo group (2.3 mm; standard deviation, 0.7; range, 0.9-3.9). Further, there were no differences in any secondary outcome measures at any postinjection follow-up interval. CONCLUSIONS: Radiocarpal joint injection of corticosteroid within 2 weeks of an intra-articular DRF does not appear to affect the development of post-traumatic osteoarthritis within 2 years follow-up in a small pilot cohort. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.