Metacarpophalangeal joint injury patterns on magnetic resonance imaging: A comparison in racing Standardbreds and Thoroughbreds.

The metacarpal condyle has received extensive attention as a predominant site of overload arthropathy in racehorses. However, detailed descriptions of MRI lesion patterns for the metacarpophalangeal joint and comparisons between types of racing horses are currently lacking. Aims of this retrospective, cross-sectional study were to describe and compare standing low-field magnetic resonance findings in the metacarpophalangeal joints for groups of Standardbreds and Thoroughbreds using systematic semiquantitative scores. Data archives at the Clinique Vétérinaire Equine de Chantilly and Imavet were searched during the period from June 2010 to February 2016. Images were retrieved and reviewed by one reader. A total of 30 Standardbreds and 77 Thoroughbreds were sampled. The Thoroughbreds developed a much higher rate of stress fractures (40.3% vs. 10%) and overall more severe scores of subchondral sclerosis and bone marrow lesions than Standardbreds. The Standardbreds had more sites of subchondral bone defect and resorption, as well as higher synovitis and joint capsule thickening scores. Both Standardbreds and Thoroughbreds frequently developed multifocal subchondral lesions not limited to the distal palmar condyle. The Standardbreds had a higher tendency to develop dorsomedial joint pole subchondral injuries. Both Standardbreds and Thoroughbreds developed a noticeably high rate of periarticular soft tissue injuries (36.7% in Standardbreds and 20.8% in Thoroughbreds), which were rarely considered as the main contributors to the lameness. Findings supported the use of low-field MRI as a whole-organ assessment tool for Standardbreds and Thoroughbreds with suspected metacarpophalangeal joint injuries.

Risk factors of hand climbing-related injuries.

This study aimed to investigate the protective mechanisms or risk factors that can be related to the occurrence of hand climbing-related injuries (CRIH ). CRIH (tendon, pulley, muscle, and joint injuries) were retrospectively screened in 528 adult climbers. The questionnaire contained anthropometric items (e.g., body mass index - BMI), as well as items regarding climbing and basic training activities (warm-up, cool-down and session durations, number of session per week, hydration, practice level, climbing surface, and duration of the cardiovascular training). Higher skilled climbers and climbers with BMI above 21 kg/m(2) were more likely to have experienced CRIH (P < 0.01). Climbers with BMI above 20 kg/m(2) were more likely to have tendon injuries while those with a BMI above 21 kg/m(2) were more likely to have pulley injuries (P < 0.01). Skilled climbers, who climb more difficult routes, may use smaller grip size and a reduced number of fingers. Higher BMI will require a higher force to climb. Both high level and elevated BMI may increase the demands to the hands and fingers leading to CRIH . These risk factors are difficult to address as we cannot recommend the climbers to climb easier routes and decrease their BMI below 20 kg/m(2) .

Comprehensive musculoskeletal sonographic evaluation of the hand and wrist.

Sonography is widely used for evaluation of hand and wrist lesions. The easy accessibility, cost-effectiveness, and good diagnostic accuracy of sonography coupled with the numerous benefits of real-time imaging make it desirable. The aim of this article is to describe the typical sonographic appearances of lesions in the hand and wrist that are encountered frequently in routine clinical practice, such as inflammatory arthropathies, tumors, traumatic injuries, foreign bodies, and nerve entrapment syndromes. Relevant anatomy, scanning methods, and recent developments in musculoskeletal sonography are also discussed.

Higher stability with locking plates in hand surgery? Biomechanical investigation of the TriLock system in a fracture model.

PURPOSE: The aim of this study was to determine the biomechanical characteristics of locking plates with the TriLock system with different design and screw settings compared to a non-locking plate in a diaphyseal metacarpal fracture. METHODS: Oblique diaphyseal shaft fractures in porcine metacarpal bones were created in a biomechanical fracture model. After reduction they were fixed with three different locking plates with the TriLock interlocking mechanism or a non-locking linear plate in mono- or bicortical screw fixations. In load to failure tests the maximum load and stiffness were measured. RESULTS: For linear plates, the maximum load was higher for the non-locking plate compared with the locking plate. The maximum load could be increased for the locking plates using a double-row design and a higher screw number. No differences were found for the stiffness between all groups. In contrast to the non-locking plate, the mode of failure of the locking plates in many cases (86 %) was a loss of the interlocking mechanism. CONCLUSIONS: The results suggest that the locking plates with the TriLock system achieve no higher stability compared to a non-locking plate in load to failure tests. Adaptions to increase the stability of the interlocking mechanism are desirable.

Use of the Bridge Plate Technique for the Treatment of Hamatometacarpal Fracture-Dislocations.

Background: This study aimed to describe a novel surgical technique in which a bridge plate was used for the treatment of hamatometacarpal fracture-dislocations and to assess its radiologic and clinical outcomes. Methods: A retrospective review of 16 patients treated with the bridge plate technique for hamatometacarpal fracture-dislocations was performed between 2010 and 2015. Clinical and radiographic evaluations were performed at months 3, 6, and 12 postoperatively. Active wrist and metacarpophalangeal joint ranges of motion and Quick Disabilities of Arm, Shoulder, and Hand (DASH) scores were recorded for the injured hands. Grip strength data were collected for both the injured hands and the contralateral uninjured hands. Results: All patients included in our study were male (mean age 31 years). The average Quick DASH score was 24.3 ± 9.1 at 3 months, 12.3 ± 7.3 at 6 months, and 6.2 ± 6.6 at 12 months. All patients returned to their original jobs within 5 weeks of the procedure. Grip strength eventually recovered to 90% of that of the uninjured hand, and none of the patients complained of finger or wrist joint stiffness. Conclusions: The use of the bridge plate technique may be an effective alternative treatment for patients with comminuted hamatometacarpal fracture-dislocations.

Bridge plating of the wrist for temporary stabilization of concomitant radiocarpal, intercarpal, and carpometacarpal injuries: a report of two cases.

Concomitant injuries of the radiocarpal, intercarpal, and carpometacarpal joints are rare and usually result from very high-energy trauma. The skeletal injury is often accompanied by severe soft tissue trauma. Repair of the radiocarpal and intercarpal ligaments needs to be augmented with immobilization. Traditional methods of immobilization, such as casts and external fixators have limitations. We describe our experience in 2 patients using a technique in which a wrist arthrodesis plate is temporarily placed from the radius to metacarpal to span the carpus and protect the radiocarpal and intercarpal repairs. The plate is removed after 3 months.

Heterogeneity of Cortical Breaks in Hand Joints of Patients with Rheumatoid Arthritis and Healthy Controls Imaged by High-resolution Peripheral Quantitative Computed Tomography.

OBJECTIVE: Conventional radiographs (CR) of the hands are the gold standard for imaging bone erosions. The presence of bone erosions, reflected by the presence of cortical breaks, is a poor prognostic factor in patients with rheumatoid arthritis (RA). The availability of high-resolution peripheral quantitative computed tomography (HR-pQCT) enables detailed investigation of cortical breaks in rheumatic diseases. The aim of this image review is to show HR-pQCT images of the spectrum of cortical breaks with and without underlying trabecular bone changes in metacarpophalangeal (MCP) joints of healthy controls (HC) and patients with RA, with corresponding images on CR and magnetic resonance imaging (MRI). METHODS: Second and third MCP joints of 41 patients (of which 10 were early RA with ≤ 2 years and 24 longstanding RA with ≥ 10 years of disease duration) and 38 HC were imaged by CR, MRI, and HR-pQCT (XtremeCT1, Scanco Medical AG). Representative images of the spectrum of cortical breaks were selected. RESULTS: Cortical breaks were found in early and longstanding RA, but also in HC. They were heterogeneous in size, location, and number per joint, with a variety of surrounding cortical and underlying trabecular bone characteristics. CONCLUSION: Using HR-pQCT images of MCP joints, heterogeneous cortical breaks with and without surrounding trabecular bone changes were found, not only in RA but also in HC. The underlying mechanisms and significance of this spectrum of cortical breaks as found with high 3-D resolution needs further investigation.

Management of complications of periarticular fractures of the distal interphalangeal, proximal interphalangeal, metacarpophalangeal, and carpometacarpal joints.

Fractures involving the bones of the hand are among the most common injuries in the United States. A significant portion of these fractures are periarticular. Although the great majority of these fractures are treated successfully by nonoperative means, complications arise. We present a comprehensive review of prevention and management of complications of periarticular fractures of the distal interphalangeal, proximal interphalangeal, metacarpophalangeal, and carpometacarpal joints.

The management of complications of small joint arthrodesis and arthroplasty.

Arthrodesis and arthroplasty are surgical options used for the management of pain, stiffness, deformity, and instability related to arthritis and traumatic injury of the small joints of the hand. Arthrodesis and arthroplasty come with a risk of postoperative infection. Superficial soft tissue infections can often be managed with oral antibiotics alone. Deep infections and osteomyelitis frequently require removal of hardware in addition to antibiotics and may require surgical revision once the infection is cleared. Selection of the most appropriate revision technique depends on the underlying cause of the initial failure, patients' functional and outcome needs, and surgeon preference.

The non-operative management of hand fractures.

Most hand fractures can be treated non-operatively. Some hand fractures, such as open injuries or markedly displaced intra-articular fractures, are almost always treated operatively. The treatment of many fractures, such as proximal interphalangeal joint fracture subluxations or spiral phalangeal fractures, is unclear. The aim of this review is to establish those injuries where the outcome of non-operative treatment is unlikely to be improved with surgery. This may help to prevent unnecessary surgery, concentrate work on finding the sub-groups that may benefit from surgery and to establish which injuries do so well with non-operative treatment that the only valuable clinical research in future will be large cohort studies of non-operative treatment or randomized controlled trials comparing operative and non-operative treatments. The relevant fractures are spiral metacarpal fractures, transverse metacarpal shaft and neck (boxer's) fractures, base of proximal phalanx avulsion fractures, thumb metacarpophalangeal joint ulnar and radial collateral ligament injuries and bony mallet injuries. For the majority of these injuries, current knowledge suggests that the outcome of non-operative treatment cannot reliably be improved upon with surgery.

The management of clenched fist 'fight bite' injuries of the hand.

We present a prospective study outlining the management of clenched fist 'fight bite' injuries. Over a 4-year period all patients with such injuries had surgical exploration with further débridements as necessary. For metacarpophalangeal joint injuries, a midline tendon-splitting approach was used. For proximal interphalangeal joint injuries, an approach was made between the lateral band and central slip of the extensor mechanism. A total of 147 patients with 159 joint injuries were treated, with 130 metacarpophalangeal joint and 29 proximal interphalangeal joint injuries. The joint was penetrated in 96% of joints overall. The number of débridements ranged from two to eight. Twenty patients defaulted within 1 week of surgery and were not included in the analysis of the results. All patients with metacarpophalangeal joint injury had satisfactory or good outcomes. A total of 42% of patients with proximal interphalangeal joint injuries had poor results, four requiring amputation and one a fusion. The tendon-splitting approach to the metacarpophalangeal joint allows excellent access and avoids damage to the sagittal bands and consequent instability of the extensor mechanism.

Reconstrução tardia na mão traumatizada com perda de múltiplos dedos / Late reconstruction of a traumatized hand with loss of multiple fingers

As lesões mutilantes de mão são um desafio para o cirurgião de mão e o paciente. O cirurgião deve tomar decisões desde o debridamento inicial, escolhendo quais dedos e articulações serão preservadas e uso apropriado das partes a serem retiradas. A reconstrução tardia é a segunda parte dessa difícil tarefa. Dificuldade que se atribui à particularidade de cada lesão, do grande número de possibilidades de tratamento e seus diversos níveis de complexidade que devem ser adequados à necessidade e motivação pessoal de cada paciente. Este relato de caso apresenta uma reconstrução tardia de mão com perda de indicador e dedo médio com transplante de articulação metacarpofalângica de indicador para função de interfalangeana proximal de dedo médio.

Mutilating hand injuries are a challenge to both the hand surgeon and the patient. The surgeon must make decisions ranging from the initial debridement to which fingers and joints will be preserved and the appropriate use of the parts to be removed. Late reconstruction constitutes the second part of this difficult task. The difficulty attributed to the characteristics of each lesion, the large number of treatment possibilities, and the different levels of complexity must be adapted to the personal needs and motivation of each patient. This case report describes a late hand reconstruction with index and middle finger loss, using metacarpophalangeal joint transplantation of the index finger to gain the proximal interphalangeal function of the middle finger.

Proximal interphalangeal joint fractures of the hand: treatment with an external dynamic traction device.

The authors present a series of 11 consecutive patients who sustained an intra-articular fracture of the proximal interphalangeal (PIP) joint and 1 patient with a fracture of the interphalangeal joint of the thumb treated with a Kirschner wire external dynamic traction device. Range of motion and grip strength were measured. We used the Michigan Hand Outcome Questionnaire (MHQ) to obtain a subjective response to the treatment. Average range of motion of the PIP joint was 64 degrees and distal interphalangeal joint was 52 degrees . The average grip strength was 86% with a mean MHQ score of 90. Two patients had pin site infections treated successfully with antibiotics. All fractures had united at final follow up with <1-mm articular step present. Our series highlights that these are difficult injuries to treat and that anatomic reduction is not always possible. However, this technique is simple and quick to perform while allowing early joint mobilization. The subjective response to treatment is comparable with other studies using a similar device.

Trapeziometacarpal subluxation predisposes to incident trapeziometacarpal osteoarthritis (OA): the Framingham Study.

OBJECTIVE: Osteoarthritis (OA) of the thumb carpo-metacarpal joint is a common condition that can lead to substantial pain, instability, deformity, and loss of motion. It has been hypothesized that instability of the trapeziometacarpal joint combined with strenuous use can potentially lead to OA. However, as yet there have been no longitudinal evaluations to determine if this hypothesis is true. We examined the relation of radial subluxation to the risk of radiographic OA at trapeziometacarpal joint. METHODS: We conducted a nested case-control study. We restricted our evaluation of cases to subjects with no radiographic trapeziometacarpal OA at baseline (1967). We defined incident trapeziometacarpal OA as the development of a modified Kellgren and Lawrence grade>or=2 in that joint at a later examination (1992-1993). Radial subluxation of the base of the first metacarpal off the trapezium and the amount of the base of the first metacarpal covering the articulating surface of the trapezium were measured using a digital calculation caliper. We examined the relation of gender-specific quartile groups of radial subluxation to the risk of trapeziometacarpal OA using a conditional logistic regression model. RESULTS: We assessed 203 men and 431 women. After adjusting for age, handedness, number of other joints with OA, and grip strength, the odds ratios for the risk of trapeziometacarpal OA in men were 1.0, 1.8, 2.7, and 3.1 from the lowest quartile of radial subluxation to the highest quartile, respectively (P for trend=0.015). There was no significant relationship between radial subluxation quartiles and incident trapeziometacarpal OA in women. CONCLUSION: This study provides evidence that radial subluxation predisposes to subsequent OA of the trapeziometacarpal joint in men.

An interpreter's interpretation: sign language interpreters' view of musculoskeletal disorders.

INTRODUCTION: Sign language interpreters are at increased risk for musculoskeletal disorders associated with work. Previous studies have used survey techniques to identify potential risk factors and approaches to their medical management. Little is known about risk factors and management of symptoms in this group from the perspective of the interpreter. Such qualitative information should help inform future research related to this professional group. METHOD: One thousand ninety-two sign language interpreters recruited from the Registry of Interpreters for the Deaf completed an open-ended question that was a component of a national prevalence survey. Responses were evaluated using content analysis. Inter and intra rater reliability were high (.88 and .92, respectively). RESULTS: Risk factors for initiation and/or exacerbation of symptoms included: difficult job, interpreting setting (educational), interpreting style (e.g., posture, self generated force), and emotional and physical stressors. Exercise (e.g., stretching, aerobics) was a common prevention strategy. Conventional medical treatment was used as the first line approach to symptom control. Self-care methods such as exercise, diet and warm up prior to interpreting were also reported. While massage and chiropractic care was used as commonly as in the general population, acupuncture was found to be used more often. Coping strategies that were more active (e.g. exercise, diet, more control over work schedule) were also reported as useful. CONCLUSIONS: These findings provide a description of factors that interpreters view as important in the development and exacerbation of hand and wrist pain. The results also indicate that interpreters used many self-management approaches. Future research should carefully investigate the utility of such approaches using well-controlled designs. Also, because of its widespread use in this group the evaluation of acupuncture in the management of these symptoms appears warranted. The qualitative approach used in the present study permitted an analysis of the worker perspectives regarding risk and management of these work related symptoms. This information can be used to further inform future research.