Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint.

BACKGROUND: Ulnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget). PURPOSE: In this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury. STUDY DESIGN: This was a prospective cohort study. METHODS: Forty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher's exact if the expected cell count was less than five. RESULTS: Patients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) CONCLUSIONS: The weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

Assessing Diagnostic Accuracy of Four-dimensional CT for Instable Scapholunate Dissociation: The Prospective ACTION Trial.

Background Timely treatment of scapholunate instability depends on early identification, but current imaging methods are either intricate or fail to demonstrate the dynamic stages. Purpose To calculate the diagnostic accuracy of four-dimensional (4D) CT for diagnosing instable scapholunate ligament (SLL) tears. Materials and Methods This prospective study enrolled consecutive participants with clinically suspected SLL tears who underwent 4D CT from July 2020 to May 2022. A historical study sample diagnosed at cineradiography served as a comparison, and wrist arthroscopy was the reference standard. Scapholunate joints greater than 3 mm were interpreted as instable at index 4D CT and cineradiography. Diagnostic accuracy was expressed as sensitivity and specificity. Areas under the receiver operating characteristic curve and cutoff values for both index tests were calculated. Intraclass correlation coefficients (ICCs) were computed to compare interrater reliability. Effective radiation doses at 4D CT were measured with thermoluminescent dosimeters. Results The study included 40 participants (mean age, 43 years ± 14 [SD]; 24 male) evaluated at 4D CT and 78 patients (mean age, 45 years ± 11; 50 male) historically evaluated at cineradiography. Four-dimensional CT helped detect instable tears in 26 of 35 participants (sensitivity, 74.3% [95% CI: 56.7, 87.5]. Cineradiography revealed instable tears in 52 of 63 patients (sensitivity, 82.5% [95% CI: 70.9, 91]). Four of five participants with stable scapholunate joints were identified at 4D CT (specificity, 80.0% [95% CI: 28.4, 99.5]), and 12 of 15 patients with stable SLLs were identified at cineradiography (specificity, 80.0% [95% CI: 51.9, 95.7]). Interrater agreement of radiologic measurements on 4D CT scans was good to excellent (ICC range, 0.89-0.96). The effective radiation dose ranged from 67 to 72 mSv at the wrist and was less than 1 mSv at the head. Conclusion Four-dimensional CT results are highly reproducible. Instable scapholunate joints greater than 3 mm were detected with a sensitivity of 74.3% and a specificity of 80% in an exploratory trial. Further evidence from larger randomized trials is warranted. German Register for Clinical Trials no. DRKS00021110 (Universal Trial Number U1111-1249-7884) Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Demehri and Ibad in this issue.

What Is the Diagnostic Accuracy of Flat-panel Cone-beam CT Arthrography for Diagnosis of Scapholunate Ligament Tears?

BACKGROUND: Cone beam CT (CBCT) is a widely available technique with possible indications in carpal ligament injuries. The accuracy of CBCT arthrography in diagnosing traumatic tears of the scapholunate ligament has not been reported. QUESTIONS/PURPOSES: (1) What is the diagnostic accuracy of CBCT and how does it relate to the accuracy of multislice CT arthrography and conventional arthrography in diagnosing scapholunate ligament tears? (2) What is the estimated magnitude of skin radiation doses of each method? METHODS: This secondary analysis of a previous prospective study included 71 men and women with suspected scapholunate ligament tears and indications for arthroscopy. Preoperative imaging was conventional arthrography and either MSCT arthrography for the first half of patients to be included (n = 36) or flat-panel CBCT arthrography for the remaining patients (n = 35). Index tests identified therapy-relevant SLL tears with dorsal or complete SLL ruptures, and these tears were compared with relevant SLL tears which were determined through arthroscopy as Geissler Stadium III and IV by probing the instable SL joint with a microhook or arthroscope. These injuries were treated by open ligament repair and Kirschner wire fixation. Accuracy values and 95% confidence intervals were calculated. Additional estimates of the radiation skin doses of each CBCT exam and two MSCT protocols were subsequently calculated using dose area products, dose length products, and CT dose indices. RESULTS: The diagnostic accuracy was high for all imaging methods. 95% CIs were broadly overlapping and therefore did not indicate differences between the diagnostic groups: Sensitivity of CBCT arthrography was 100% (95% CI 77 to 100), specificity was 95% (95% CI 76 to 99.9), positive predictive value was 93% (95% CI 68 to 99.8), and negative predictive value was 100% (95% CI 83 to 100). For MSCT arthrography, the sensitivity was 92% (95% CI 64 to 99.8), specificity was 96% (95% CI 78 to 99.9), positive predictive value was 92% (95% CI 64 to 99.8), and negative predictive value was 96% (95% CI 78 to 99.9). For conventional arthrography, the sensitivity was comparably high: 96% (95% CI 81 to 99.9). Specificity was (81% [95% CI 67 to 92]); the positive predictive value was 77% (95% CI 59 to 89) and negative predictive value was 97% (95% CI 86 to 99.9). Estimated mean (range) radiation skin doses were reported in a descriptive fashion and were 12.9 mSv (4.5 to 24.9) for conventional arthrography, and 3.2 mSv (2.0 to 4.8) for CBCT arthrography. Estimated radiation skin doses were 0.2 mSv and 12 mSv for MSCT arthrography, depending on the protocol. CONCLUSION: Flat-panel CBCT arthrography can be recommended as an accurate technique to diagnose scapholunate ligament injuries after wrist trauma. Estimated skin doses are low for CBCT arthrography and adapted MSCT arthrography protocols. LEVEL OF EVIDENCE: Level III, diagnostic study.

ACTION trial: a prospective study on diagnostic Accuracy of 4D CT for diagnosing Instable ScaphOlunate DissociatioN.

BACKGROUND: Early detection of scapholunate ligament (SLL) tears is essential after minor and major trauma to the wrist. The differentiation between stable and instable injuries determines therapeutic measures which aim to prevent osteoarthritis. Arthroscopy has since been the diagnostic gold standard in suspected SLL tears because non-invasive methods have failed to exclude instable injuries reliably. This prospective study aims to determine the diagnostic accuracy of dynamic, 4D computed tomography (CT) of the wrist for diagnosing instable SLL tears. METHODS: Single center, prospective trial including 40 patients with suspected SLL tears scheduled for arthroscopy. Diagnostic accuracy of 4D CT will be tested against the reference standard arthroscopy. Radiologists will be blinded to the results of arthroscopy and hand surgeons to radiological reports. A historical cohort of 80 patients which was diagnosed using cineradiography before implementation of 4D CT at the study site will serve as a comparative group. DISCUSSION: Static imaging lacks the ability to detect instable SLL tears after wrist trauma. Dynamic methods such as cineradiography and dynamic magnetic resonance imaging (MRI) are complex and require specific technical infrastructure in specialized centers. Modern super-fast dual source CT scanners are gaining popularity and are being installed gradually in hospitals and ambulances. These scanners enable dynamic imaging in a quick and simple manner. Establishment of dynamic 4D CT of the wrist in patients with suspected SLL tears in in- and outpatient settings could improve early detection rates. Reliable identification of instable injuries through 4D CT scans might reduce the number of unnecessary diagnostic arthroscopies in the future. TRIAL REGISTRATION: This study was registered prospectively at the German Clinical Trials Register (DRKS) DRKS00021110 . Universal Trial Number (WHO-UTN): U1111-1249-7884.

Biomechanical comparison of the proximal interphalangeal joint arthrodesis using a compression wire.

INTRODUCTION/AIM: Arthrodesis of the proximal interphalangeal joint of the finger is a common procedure for the treatment of osteoarthritis. The aim of this biomechanical study was to compare the primary stability of one, respectively, two compression wires to intraosseous wiring and tension band wiring for the arthrodesis. MATERIALS AND METHODS: The stability of the arthrodesis was tested by applying flexion (n = 11) and extension (n = 10) force with 10° bending. Arthrodesis was achieved by one, respectively, two crossed compression wires and intraosseous wiring. In a control group (n = 11) tension band wiring was tested to 10° flexion and extension as well. RESULTS: Mean values for flexion bending for intraosseous wiring were 10.94 N, for one compression wire 12.82 N, for tension band wiring 17.95 N, and for two crossed compression wires 20.42 N. Mean values for extension bending were 9.71 N for intraosseous wiring, 13.63 N for one compression wire, 21.43 N for tension band wiring and 22.56 N for two crossed compression wires. CONCLUSION: The primary stability of the compression wires was statistically significant superior to intraosseous wiring. In comparison to tension band wiring which showed an intermediate stability. The application of a compression wire could be considered for further clinical testing in the arthrodesis of interphalangeal joints.

Accuracy of simple plain radiographic signs and measures to diagnose acute scapholunate ligament injuries of the wrist.

OBJECTIVE: To determine the accuracy of common radiological indices for diagnosing ruptures of the scapholunate (SL) ligament, the most relevant soft tissue injury of the wrist. METHODS: This was a prospective diagnostic accuracy study with independent verification of index test findings by a reference standard (wrist arthroscopy). Bilateral digital radiographs in posteroanterior (pa), lateral and Stecher's projection were evaluated by two independent expert readers. Diagnostic accuracy of radiological signs was expressed as sensitivity, specificity, positive (PPV) and negative (NPV) predictive values with 95 % confidence intervals (CI). RESULTS: The prevalence of significant acute SL tears (grade ≥ III according to Geissler's classification) was 27/72 (38 %, 95 % CI 26-50 %). The SL distance on Stecher's projection proved the most accurate index to rule the presence of an SL rupture in and out. SL distance on plain pa radiographs, Stecher's projection and the radiolunate angle contributed independently to the final diagnostic model. These three simple indices explained 97 % of the diagnostic variance. CONCLUSIONS: In the era of computed tomography and magnetic resonance imaging, plain radiographs remain a highly sensitive and specific primary tool to triage patients with a suspected SL tear to further diagnostic work-up and surgical care. KEY POINTS: • Scapholunate ligament (SL) lesions are the most relevant soft tissue wrist injuries. • Missed and untreated SL ruptures can cause painful and disabling post-traumatic wrist osteoarthritis. • Reliable threshold values of radiographic indices should prompt further imaging or surgical care. • Plain radiographs deliver conclusive clinical information if certain hand positions are used.

The palmar approach for PIP-arthroplasty according to Simmen: results after 8 years follow-up.

BACKGROUND: Alloarthroplasty of the proximal interphalangeal joint is indicated for patients with osteoarthritis, an inflammatory disease of the joint. According to the current literature, implants made of silicone are not inferior to newer implants and the complications are well known. Therefore, focus should be shifted to the operative approach to improve the results. METHODS: Eleven silicone arthroplasties in 7 patients with arthritis and 35 silicone arthroplasties in 23 patients with osteoarthritis were reviewed after 15.6 months and after 105.3 months. All implants were inserted using the palmar approach according to Simmen. We compared the pre- and postoperative arc of motion, pain, and strength, and present postoperative complications and satisfaction. RESULTS: Patients with arthritis showed a gain in range of motion of 36° and patients with osteoarthritis of 39°. No implant failure occurred, and one revision was performed,. Average extension lag over all operated joints of patients was 2.8°. No swan-neck deformity or extensor tendon adhesion was observed. There was no significant difference in the postoperative results between patients with osteoarthritis and arthritis or between first and second follow-up. CONCLUSION: Silicone arthroplasty restores the functionality of proximal interphalangeal joints in patients with osteoarthritis and inflammatory joint disease. Using a palmar approach, the surgeon can reach palmar and dorsal osteophytes. The extensor mechanism stays intact reducing the risk for extensor lag and other complications compared to the dorsal approach. The results do not change significantly between 1 and 8 years postoperatively.

Ulnocarpal impaction syndrome: treatment with a transverse ulnar shortening osteotomy from an ulnodorsal approach.

INTRODUCTION: Ulnocarpal impaction syndrome is a common cause of chronic ulnar-sided wrist pain. The distal ulnar shortening osteotomy addresses the often present positive ulnar variance and therefore relieves the excessive load on the ulnocarpal joint. In the present study, the results of a technique that uses an ulnodorsal approach with a compression device and a transverse osteotomy are presented and compared to other techniques. MATERIALS AND METHODS: This retrospective study includes 92 wrists with an ulnocarpal impaction syndrome, which were treated with an ulnar shortening osteotomy. The mean duration of postoperative follow-up was 50 months. RESULTS: The mean ulnar variance was 2.17 ± 1.56 mm preoperatively and after the ulnar shortening osteotomy -1.36 ± 1.67 mm (p < 0.05). Radiological consolidation of the osteotomy could be shown in 91 wrists 6 months postoperatively. Patients rated the preoperative pain level at a VAS 7.9 ± 1.7 which decreased to a of VAS 2.4 ± 2.5 (p < 0.05). 19 patients complained of mechanical irritation. There was no neurological irritation. CONCLUSION: It could be shown that the distal ulnar shortening osteotomy by a transverse osteotomy using a compression device and an ulnodorsal approach has a low complication rate. It is comparable to the oblique osteotomy in effectiveness and safety.

Nodular giant cell tumour of the tendon sheath of the hand: analysis of eighty-four cases: diagnostic decisions and outcome.

INTRODUCTION: The giant cell tumour of the tendon sheath (GCTTS) of the hand is a benign tumour of unknown origin. The clinical diagnosis is supported by preoperative imaging. But the ideal imaging methods necessary for the diagnosis, preoperative planning and total tumour resection are still debated. Standard treatment is surgical resection with histological confirmation. METHODS: We followed up 84 patients who were operated upon for a histologically confirmed nodular type GCTTS for an average of 4.7 years (range four to eight). The preoperative symptoms and radiological findings of X-ray, ultrasound and MRI were reviewed and the surgeon asked for their impact on the surgical procedure. RESULTS: The average age at operation was 50.9 years, 65.5% of the patients were female and 61.9% of the lesions were located on the palmar aspect. Most tumours were found on the first three fingers. Two patients had tumours at two separate sites (2.4%). After an average follow up of 31.5 months two recurrences were observed (2.4%). In addition to X-ray and ultrasound, the preoperative findings of the MRI had no influence on the surgical procedure. CONCLUSION: Our data on the nodular GCTTS are in accordance with published data concerning the age distribution, gender distribution, and localisation. No soft-tissue imaging method is superior for the diagnosis of nodular GCTTS or for the preoperative planning. A preoperative MRI may not be necessary as clinical and ultrasound examination are sufficient. To exclude bony erosions, a preoperative X-ray is necessary.

Results of Mannerfelt wrist arthrodesis for rheumatoid arthritis in relation to the position of the fused wrist.

PURPOSE: The wrist is involved early in rheumatoid arthritis and is often severely affected. A stable wrist is crucial to good hand function, which often necessitates a fusion. One of the most commonly used techniques in rheumatoid patients is the Mannerfelt arthrodesis. In this retrospective study the outcome and the patient's subjective satisfaction are presented and compared to other techniques. Also the influence of the position of the wrist following a fusion procedure is analysed. METHODS: Thirty-four wrists were retrospectively analysed using radiological measurements, functional scores such as the Disabilities of the Arm, Shoulder and Hand (DASH) and a pain assessment. The objective function of the hand with the fused wrist was assessed. RESULTS: In 92.6% of wrists the patients rated their satisfaction as good or excellent. The mean DASH score post-operatively was 63.3. Of the wrists, 17 were fixed in a median flexed position of 13° and 17 wrists in a median extended position of 8°. There was no statistically significant correlation between the position of the wrist and the satisfaction or objective function. The rate of fusion was 94.1%. CONCLUSIONS: The Mannerfelt arthrodesis achieves good results and provides a high rate of satisfaction and pain relief in our study. It has major advantages compared to other wrist fusion techniques in the rheumatoid patient. We could not show clear statistical evidence for better results in either a flexed or an extended position, but the ratings of the patients indicated better subjective results with a slightly extended position of the arthrodesis.

Superselective Catheter Angiographies of the Wrist (SCAW): Approaches for Vascularized Bone Grafts.

Background: This study assesses the variability of the palmar radiocarpal artery (PRCA), dorsal carpal branch of the ulnar artery (DCBUA), and anterior interosseous artery (AIA) in superselective catheter angiographies of the wrist (SCAW). Methods: Secondary analysis of consecutive SCAW (2009-2011). Measurements of the distances of the PRCA to the midface of the radiocarpal joint, the DCBUA to the styloid process of the ulnar, and maximum diameters of PRCA, DCBUA, and AIA. Results: Seven female and ten male patients (mean 35 years) received SCAW. All patients suffered from Kienbock's disease. The mean distance from the PRCA to the radiocarpal joint was 7.9 ± 2.3 mm and the distance from the DCBUA to the styloid process of the ulna was 29.6 ± 13.6 mm. The mean maximum diameter of the PRCA was 0.6 ± 0.2 mm, that of the DCBUA was 1.1 ± 0.4 mm, and that of the AIA 1.2 ± 0.3 mm. In six cases (35%), all three arteries contributed to the PRCA; in eight cases (47%), the radial and AIA; in two cases (12%), the radial and ulnar artery; and in one case (6%), only the radial artery contributed. Conclusions: SCAW are feasible to assist in preoperative planning. Os pisiforme transfer with DCBUA might be the best choice for a vascular bone graft in Kienbock's disease.

Arthrodesis of the Proximal Interphalangeal Joint of the Finger-A Biomechanical Study of Primary Stability.

BACKGROUND: Osteoarthritis of the proximal interphalangeal (PIP) joint of the finger often leads to global hand-function detriment. Different techniques for the arthrodesis of the proximal interphalangeal joint have been described that all lead to union in a reasonable percentage of patients and period of time. This biomechanical study aims to analyze and compare the primary stability of different techniques of arthrodesis to render postoperative immobilization unnecessary. METHODS: Arthrodeses of 40° of composite cylinders were tested with different techniques in four-point bending for stability in extension as well as flexion. RESULTS: In extension, the compression screw and the compression wires showed the highest stability-whereas in flexion, plate fusion was superior. Tension band, cerclage or compression screw fusion showed the best compromise in flexion/extension stability. CONCLUSIONS: Fusion techniques that apply compression to the fusion show superior stability. Cerclage, tension band and compression screws might be able to provide enough stability to withstand the forces exerted during unencumbered activities of daily living. Arthrodesis with plates should be limited to patients with special indications and require immobilization during consolidation.

[Arthrodesis of the distal interphalangeal Joint - a literature Review]. / Die Arthrodese des Fingerendgelenkes: eine Literaturanalyse.

This review addresses the arthrodesis of the distal interphalangeal joint of the finger and the interphalangeal joint of the thumb with focus on indications, approaches, preparation of the articular surfaces, the angle of arthrodesis, advances and disadvantages of each technique, and postoperative care.

Intramedullary Single-Kirschner-Wire Fixation in Displaced Fractures of the Fifth Metacarpal Neck (Boxer's Fracture).

The fracture of the fifth metacarpal neck (also called a boxer's fracture) is the most common fracture of the hand1,3. Displaced fractures often result in volar angulation of the metacarpal head, shortening, and residual malrotation4-7. The present video article demonstrates the steps of performing intramedullary single-Kirschner-wire fixation of the fifth metacarpal neck1, with the aim of the procedure being to achieve a closed reduction and internal stabilization of such a fracture. Although many fractures can be treated with a splint only, surgery should be performed in patients with excessive volar angulation, relevant shortening, or rotational deformity5-7. Description: For this procedure, the injured arm of the patient is placed on an arm table. The incision is made 1 to 2 cm longitudinally over the ulnar base of the fifth metacarpal bone. The cortical bone is opened with an awl, and a bent 1.6-mm Kirschner wire is inserted into the medullary canal. After reaching the fracture region, the fracture is anatomically reduced. The Kirschner wire is then advanced into the head of the fifth metacarpal, securing the reduction. Malrotation can be addressed in this stage by rotating the wire under fluoroscopic control. After ensuring anatomical reduction clinically and by fluoroscopy, the wire is shortened under the skin, followed by closure of the incision. We utilize a mid-hand brace for splinting. Alternatives: Nonoperative treatment is common for fifth metacarpal neck fractures in the absence of malrotation, excessive angulation, and shortening. Other surgical techniques include a similar procedure that involves the use of multiple Kirschner wires, plate fixation, transverse Kirschner wire pinning, and, less commonly, retrograde headless screw fixation2,7-9. Rationale: The main advantage of this technique is the preservation of the metacarpophalangeal joint and the minimal soft-tissue damage. Additionally, the use of a single Kirschner wire provides stability at low cost. With some experience, this surgery can be performed within 20 minutes1,9. Expected Outcomes: This procedure provides good fracture reduction and stabilization8. The outcome is usually satisfactory, with very low Disabilities of the Arm, Shoulder, and Hand scores1. Malrotation, angulation, and shortening are sufficiently addressed, and the technique shows the same results as fixation performed with use of 2 intramedullary wires. Important Tips: Bending the Kirschner wire to ensure easy gliding in the medullary canal provides the opportunity to reduce the metacarpal neck once the wire is safely in the head.Aim distally as you open the cortical bone with the awl in order to facilitate the insertion of the Kirschner wire.The primary reduction should be made manually, not by the wire. Subacute fractures and substantially displaced fractures require direct force for a satisfactory reduction, which cannot be achieved by rotation of the wire only.The cortical bone on the metacarpal head is very thin. Take care not to drive the Kirschner wire through the cortical bone and into the joint.Shorten the wire under the skin approximately 1 cm above the bone surface; this ensures easy removal and prevents skin irritation. Acronyms and Abbreviations: K-wire = Kirschner wire.

[Infections of the Hand after Bite Injuries]. / Infektionen an der Hand nach Bissverletzungen.

Bite injuries are common. Along with the resulting complications, they represent approximately 1-2 % of all emergency department visits. In over 75 %, the hands are affected. In Northern Europe, bites and subsequent infections are mainly caused by dogs and cats but also by humans.Up to 40 % of all hand infections are caused to bite injuries. Due to the multiple and complex compartments as well as the low soft tissue coverage of functionally relevant structures, even the smallest and most superficial bite injuries of the hand lead to infections. Any bite injury to the hand may subsequently may result in a fulminant infection and, rarely, even death.The spectrum of pathogens from the oral flora of the biting animal or person is diverse and includes aerobic and anaerobic bacterial strains. Bite injuries represent a major challenge for both the injured person and the attending physician. The rate of complications has been shown to increase with delayed medical consultation, lack of medical care and inadequate wound care. In this review, we discuss the types and complications of bite wounds, their potential risk of infection, their pathogen spectrum and appearance, and their effective treatment.

Comparison of Calculated Skin Doses in Cineradiography and Four Dimensional Kinematic Computed Tomography of the Wrist.

Background: Previous studies have discussed the diagnostic value of four dimensional kinematic CT in cases of carpal instabilities. This analysis compares calculated skin doses of 4D CT and conventional cineradiography of the wrist in cases of suspected SLL rupture. Methods: Retrospective calculation and interpolation of skin doses and effective doses for ten consecutive 4D CT examinations and 41 cineradiographies for suspected lesions of the scapholunate ligament. Standardised anterior-posterior and lateral cine sequences using a flat-panel digital subtraction imager and of 4D kinematic CT using a dual-source scanner were acquired and acquisition parameters recorded. We tested if the skin dose of 4D CT is different from cineradiography. Results: Median dose area product (DAP) of cineradiography was 135.34 cGycm2 resulting in a calculated median skin dose of 32.6 mSv (confidence interval 26.86-42.90 mSv) and an estimated effective skin dose of 3.26 µSv. CT dose index (CTDI) for 4D examinations was recorded to be 26.79 mGy and the dose-length product (DLP) was 150 mGy × cm. This resulted in an estimated skin dose of 34 mSv, which is covered by the confidence interval of cineradiography, and an effective skin dose of 3.4 µSv. Conclusions: Skin dose calculations are comparable for 2D cineradiography in two plains and 4D kinematic CT of the wrist. Calculated effective doses are < 0.01 mSv.

[Osteitis/Osteomyelitis of the Hand and Wrist]. / Osteitis/Osteomyelitis an Hand und Handgelenk.

Osteomyelitis of the hand and wrist is uncommon compared to the infections of the long bones but not rare. There is poor evidence on many answers to questions concerning this disease. This includes careful consideration of the prevalence, pathogenesis, microbiology, diagnostic methods and the conservative, medical and surgical treatment. The emergence of the disease can subdivided in post-traumatic, postoperative, spread from contiguous infections and hematogenous. The individual patient-specific risk must be considered. Early diagnosis and correct management are essential to preserve bony structures and the articular function of the hand. A two-step surgical procedure is usually necessary, but uncertainties about the optimal treatment are still existing. Satisfactory control rates of the infection and successful bone reconstructions can be achieved. But complications, a limited range of motion and amputations of finger parts can still not be avoided in all cases.

[Septic Arthritis of the Hand and Wrist]. / Gelenkinfektionen an Hand und Handgelenk.

This review article addresses the epidemiology, ethology, clinic, diagnostics and therapy of infections of the wrist and small joints of the hand.

[Input of the start on the result of a special interdisciplinary rehabilitation program for work-related injuries of the hand]. / Einfluss des Beginns auf das Ergebnis einer spezialisierten Handrehabilitation bei beruflichen Handverletzungen.

PURPOSE: The objective of this study was to evaluate the outcome of a special interdisciplinary hand therapy program depending on the time interval between trauma and rehabilitation. PATIENTS AND METHODS: With use of self-assessed scores (Disability of the Arm, Shoulder and Hand Score [DASH-Score], European Quality of Life 5 Dimensions [EQ-5D]) and objective functional parameters (TAM = Total Active Motion for finger injuries, ROM = Range of Motion for wrist injuries, grip strength) the outcome of 76 patients with injuries of the fingers, wrist or a complex regional pain syndrome (CRPS) was analysed at the begin and end of an inpatient rehabilitation and at a follow-up examination after 12 to 16 weeks. The patients were divided into groups with an early (< 120 days after trauma) or late beginning of their rehabilitation. RESULTS: At the follow-up examination early beginners had a significant better DASH-Score as well as a ROM. At the end of the rehabilitation program and at the time of the follow-up examination significant more patients with an early as patients with a late start of the rehabilitation were back to work. Especially patients with CRPS and finger injuries benefit from an early start of the rehabilitation. CONCLUSION: Compared to a late start an early start of a rehabilitation program after finger and hand injuries and a CRPS leads to better functional with special benefit for patients with a CRPS.

Study of Medical Ultrasound for Rhizarthrosis (SUR): study protocol for a randomized controlled single-center pilot-trial.

BACKGROUND: Rhizarthrosis (trapeziometacarpal osteoarthritis) is the second most common site of osteoarthritis in the hand affecting 10-30% of adults over the age of 50. Up to four times as many women as men have rhizarthrosis. Clinical symptoms include functional disability of the thumb, pain, joint swelling, and reduced strength. The first carpometacarpal joint is pivotal in the opposition of the thumb and allows a high degree in flexibility to humans. Current therapies focus mainly on surgical strategies, which should be considered in advanced, therapy-resistant stages to relieve pain and improve function. However, conservative treatment methods are urgently required in presurgical stages. The efficacy of conservative treatment options for rhizarthrosis, which are intended to preserve function, joint integrity and to relieve pain, has not been adequately studied. In the clinical study protocol presented here, we investigate the efficacy of multimodal hand therapy versus therapeutic ultrasound versus combination therapy with both hand therapy and therapeutic ultrasound. METHODS: This study is a single-center, randomized, controlled, parallel-group pilot trial. One hundred fifty patients with rhizarthrosis and current disease activity will be randomized to one of three conservative interventions over 6 months. Interventions are (1) multimodal hand therapy (2) therapeutic ultrasound, and (3) combination therapy with both hand therapy and ultrasound therapy. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score after 6 months. Secondary endpoints are changes in pain, quality of life, disability progression, and changes of hand function. Safety will also be assessed. DISCUSSION: Clinical data suggest that multimodal hand therapy may improve functionality and reduce pain in rhizarthrosis. Clinical data regarding therapeutic ultrasound are not available. Clinical evidence is lacking. This study is the first clinical study investigating the effects of multimodal hand therapy in direct comparison to therapeutic ultrasound and to a combination therapy with both hand therapy and ultrasound therapy for rhizarthrosis. TRIAL REGISTRATION: ClinicalTrials.gov; NCT04115085; Registered on September 30, 2019.