Retrospective study of Ishiguro's technique for mallet bone finger in children: long-term follow-up and analysis of predictors in outcomes.

PURPOSE: There is no consensus on the optimal treatment of bony mallet finger in the paediatric population due to a lack of studies in children. The Ishiguro technique is simple and less invasive, and treatment with K-wire fixation seems to provide better results for extension lag in bony mallet finger according to the literature. A retrospective cross-sectional study with long-term follow-up was performed to evaluate the functional and clinical outcomes of this method in children. Preoperative and intraoperative predictors of outcome were investigated. METHODS: From June to December 2022, we evaluated 95 children who underwent extension K-wire block from 2002 to 2012. Eighty-four children were included (mean age 14.8 ± 1.68 years) for a mean long-term follow-up of 11.6 ± 2.3 (8-16) years. Clinical and radiographic features were assessed. Pain and functional outcomes were assessed using Crawford criteria, range of motion (ROM) at the distal interphalangeal joint (DIPJ), loss of extension, and VAS scale. Univariate and multivariate regressions were used to assess which variables might predict the worst outcomes at long-term follow-up. RESULTS: Bone union and pain relief were always achieved. There were no complaints of potential growth impairment or nail deformity. 82.1% of patients showed excellent and good results. Fifteen patients had fair results. CONCLUSIONS: Although there are currently no significant differences between surgery and orthosis in adults, the Ishiguro technique is more effective in children when it comes to outcomes in the treatment of mallet fingers. A high percentage of excellent and good results were achieved, and no epiphyseal damage or nail deformity was reported. A strong and significant correlation was found between the worst outcomes and either delayed treatment time or excessive flexion angle.

Mesenchymal PLAG1 Tumor With PCMTD1-PLAG1 Fusion in an Infant: A New Type of "Plagoma".

ABSTRACT: In the past decade, there have been major advances in knowledge related to mesenchymal tumors, and new genetic alterations are being delineated. We report a mesenchymal spindle cell neoplasm harboring a novel gene fusion in an infant. Histopathologically, the neoplasm shared some features with sclerosing perineurioma, but immunohistochemically, EMA was negative, whereas GLUT1, NK1-C3, and BCOR were positive. Next-generation sequencing revealed a PCMTD1-pleomorphic adenoma gene 1 (PLAG1) fusion. PLAG1 contributes to the expression of a variety of genes implicated in regulating cell proliferation, and PCMTD1 has been related to the development of certain carcinomas. Recently, other soft tissue tumors in young children associated with PLAG1 fusion variants have been reported. Perhaps, mesenchymal neoplasms presenting PLAG1 fusions with different genes would confirm a specific group (PLAG mesenchymal tumours or "plagomas") in the near future.

Prognostic factors for finger interphalangeal joint osteoarthritis: a systematic review.

OBJECTIVE: Radiographic hand OA affects one in five adults. Symptomatic hand OA can result in functional impairment, pain and reduced quality of life. A prevalent form of hand OA is IP joint OA, however prognostic factors for IP joint OA remain poorly understood. This systematic review aimed to identify prognostic factors for IP joint OA, and to summarize the diagnostic criteria for IP joint OA in prognostic studies. METHODS: EMBASE, MEDLINE, Scopus and The Cochrane Library were searched from inception until 19 February 2020 (PROSPERO CRD42019116782). Eligible studies described diagnostic criteria defining IP joint OA, and assessed potential prognostic factors for IP joint OA. Risk of bias was assessed using a modified Quality in Prognosis Studies (QUIPS) tool and a best evidence synthesis was used. RESULTS: Eighteen studies were included (risk of bias: eight high, three moderate, seven low). All defined OA radiographically, and three studies incorporated clinical symptoms into their definition of OA. Forty-nine potential prognostic factors were assessed. Eight were prognostic: older age in women, female gender (both moderate evidence); family history of Heberden's nodes, Kashin-Beck disease, older age in men, dental occupation in men, finger fracture, parity (all limited evidence). Higher BMI in women (limited evidence) was prognostic for symptomatic radiographic OA. No prognostic factors for symptomatic OA were identified. CONCLUSION: IP joint OA is most commonly defined radiographically, yet criteria were heterogeneous. Eight prognostic factors for radiographic IP joint OA and one for symptomatic radiographic IP joint OA were identified, all with limited or moderate evidence. Further studies on causality and on prognostic pathways are needed.

PsART-ID inception cohort: clinical characteristics, treatment choices and outcomes of patients with psoriatic arthritis.

OBJECTIVES: Our aim is to understand clinical characteristics, real-life treatment strategies, outcomes of early PsA patients and determine the differences between the inception and established PsA cohorts. METHODS: PsArt-ID (Psoriatic Arthritis- International Database) is a multicentre registry. From that registry, patients with a diagnosis of PsA up to 6 months were classified as the inception cohort (n==388). Two periods were identified for the established cohort: Patients with PsA diagnosis within 5-10 years (n = 328), ≥10 years (n = 326). Demographic, clinical characteristics, treatment strategies, outcomes were determined for the inception cohort and compared with the established cohorts. RESULTS: The mean (s.d.) age of the inception cohort was 44.7 (13.3) and 167/388 (43.0%) of the patients were male. Polyarticular and mono-oligoarticular presentations were comparable in the inception and established cohorts. Axial involvement rate was higher in the cohort of patients with PsA ≥10 years compared with the inception cohort (34.8% vs 27.7%). As well as dactylitis and nail involvement (P = 0.004, P = 0.001 respectively). Both enthesitis, deformity rates were lower in the inception cohort. Overall, 13% of patients in the inception group had a deformity. MTX was the most commonly prescribed treatment for all cohorts with 10.7% of the early PsA patients were given anti-TNF agents after 16 months. CONCLUSION: The real-life experience in PsA patients showed no significant differences in the disease pattern rates except for the axial involvement. The dactylitis, nail involvement rates had increased significantly after 10 years from the diagnosis and the enthesitis, deformity had an increasing trend over time.

Validation of new measures of arm coordination impairment in Wheelchair Rugby.

This study aims were twofold: (1) to evaluate the construct validity of the Repetitive Movement Test (RMT) a novel test developed for Wheelchair Rugby classification which evaluates arm coordination impairment at five joints - shoulder, elbow, forearm, wrist and fingers - and (2), pending sufficiently positive results, propose objective minimum impairment criteria (MIC). Forty-two WR athletes with an eligible coordination impairment, and 20 volunteers without impairment completed the RMT and two clinically established coordination tests: the finger-nose test (FNT) and the spiral test (ST). Coordination deduction (CD), an ordinal observational coordination scale, currently used in WR classification, was obtained. Spearman-rank correlation coefficients (SCC) between RMT and ST (0.40 to 0.67) and between RMT and CD (0.31 to 0.53) generally supported RMT construct validity, SCC between RMT and FNT were lower (0.12-0.31). When the scores on ST, FNT and RMT from the sample of WR players were compared with the scores from volunteers without impairment, 93.5% to 100% of WR players had scores > 2SD below the mean of volunteers without impairment on the same test. In conclusion, RMT at the elbow, forearm, wrist and fingers have sufficient construct validity for use in WR. MIC were recommended with ST and RMT.

Clinical Characteristics and Surgical Outcomes of Congenital Ulnar-deviated Thumbs: Delta Triphalangeal Thumbs and Irregular Epiphyses.

BACKGROUND: Delta triphalangeal thumbs (DTPT) and irregular epiphysis thumbs (IET) had different anatomic deformities. Our primary purpose was to evaluate the clinical and radiographic outcomes of surgical treatment in DTPT and IET. METHODS: In total, 43 ulnar-deviated thumbs were included and categorized into 2 types according to x-ray and exploration during surgery, DTPT and IET. Surgical excision of the delta phalanx in DTPT and intraepiphysis osteotomy in IET was conducted. RESULTS: In total, 23 ulnar-deviated thumbs were classified as DTPT and 20 as IET. Ten thumbs that could not be classified initially were followed-up until they could be categorized at the mean age of 24 months. The preoperative mean degrees of ulnar deviation at the interphalangeal joints were 40 and 33 degrees, in DTPT and IET, respectively. The mean degrees were 2 and 5 degrees in final follow-up, showing significant improvement (DTPT, P<0.05; IET, P<0.05). Complications during the study included residual ulnar deviation, overcorrection, and nonunion. The stability and range of movement at the interphalangeal joint were good overall. According to the Japanese Society for Surgery of the Hand scoring system, results were excellent in 29 cases, good in 13, and fair in 1. CONCLUSIONS: Ulnar clinodactyly of the thumb occurs because of different anatomic features such as DTPT or IET. We recommend surgical treatment be postponed until the anatomic abnormality can be ascertained. Furthermore, almost all patients with ulnar-deviated thumbs had significant improvement in clinical and radiographic outcomes after surgery.

Incidence and progression of hand osteoarthritis in a large community-based cohort: the Johnston County Osteoarthritis Project.

OBJECTIVE: To describe the incidence and progression of radiographic and symptomatic hand osteoarthritis (rHOA and sxHOA) in a large community-based cohort. DESIGN: Data were from the Johnston County OA Project (1999-2015, 12 ± 1.2 years follow-up, age 45+). Participants had bilateral hand radiographs each visit, read for Kellgren-Lawrence grade (KLG) at 30 joints. We defined rHOA as KLG ≥2 in ≥1 joint. SxHOA was defined in a hand/joint with rHOA and self-reported symptoms or tenderness on exam. Incidence was assessed in those without, while progression was assessed in those with, baseline rHOA. Proportions or medians are reported; differences by sex and race were assessed using models appropriate for dichotomous or continuous definitions, additionally adjusted for age, education, body mass index (BMI), and weight change. RESULTS: Of 800 participants (68% women, 32% African American, mean age 60 years), 327 had baseline rHOA and were older, more often white and female, than those without rHOA (n = 473). The incidence of HOA was high, for rHOA (60%) and for sxHOA (13%). Women were more likely than men to have incident HOA, particularly for distal interphalangeal joint radiographic osteoarthritis (DIP rOA) (adjusted odds ratios (aOR) 1.60 95% confidence intervals (95% CI) [1.03, 2.49]) and sxHOA (aOR 2.98 [1.50, 5.91]). Progressive HOA was more similar by sex, although thumb base rOA progressed more frequently in women than in men (aOR 2.56 [1.44, 4.55]). Particularly HOA incidence, but also progression, was more frequent among whites compared with African Americans. CONCLUSION: This study provides much needed information about the natural history of HOA, a common and frequently debilitating condition, in the general population.

Intrinsic plus hand: Painful Finger flexion and extension.

Intrinsic plus hand describes a rare and painful contracture of the intrinsic hand muscles with excessive flexion at the metacarpophalangeal joints and extension at the interphalangeal joints. Resulting from many causes to include trauma and neurologic injury, intrinsic plus hand can involve any number of fingers. Emergency department (ED) assessment should include evaluation for cerebrovascular injury, infection, compartment syndrome, and deep vein thrombosis (DVT). Conservative splinting is generally unsuccessful and ultimately requires operative intervention. We highlight the case of a 61-year-old otherwise healthy male who awoke to a painful and mildly swollen left hand with his fingers held in a contracted position. Evaluation in the ED found no active range of motion in the digits, severe pain with any passive motion, and a negative upper extremity ultrasound for DVT. Ultimately, orthopedic and neurology consults in the ED agreed upon a diagnosis of intrinsic plus hand.

Risk factors for the progression of finger interphalangeal joint osteoarthritis: a systematic review.

Progressive hand interphalangeal joint (IPJ) osteoarthritis is associated with pain, reduced function and impaired quality of life. However, the evidence surrounding risk factors for IPJ osteoarthritis progression is unclear. Identifying risk factors for IPJ osteoarthritis progression may inform preventative strategies and early interventions to improve long-term outcomes for individuals at risk of IPJ osteoarthritis progression. The objectives of the study were to describe methods used to measure the progression of IPJ osteoarthritis and identify risk factors for IPJ osteoarthritis progression. MEDLINE, EMBASE, Scopus, and The Cochrane Library were searched from inception to 19th February 2020 (PROSPERO CRD42019121034). Eligible studies assessed potential risk factor/s associated with IPJ osteoarthritis progression. Risk of bias was assessed using a modified QUIPS Tool, and a best evidence synthesis was performed. Of eight eligible studies, all measured osteoarthritis progression radiographically, and none considered symptoms. Eighteen potential risk factors were assessed. Diabetes (adjusted mean difference between 2.06 and 7.78), and larger finger epiphyseal index in males (regression coefficient ß = 0.202) and females (ß = 0.325) were identified as risk factors (limited evidence). Older age in men and women showed mixed results; 13 variables were not risk factors (all limited evidence). Patients with diabetes and larger finger epiphyseal index might be at higher risk of radiographic IPJ osteoarthritis progression, though evidence is limited and studies are biased. Studies assessing symptomatic IPJ osteoarthritis progression are lacking.

Poor prognostic factors in predicting abatacept response in a phase III randomized controlled trial in psoriatic arthritis.

In ASTRAEA (NCT01860976), abatacept significantly increased American College of Rheumatology criteria 20% (ACR20) responses at Week 24 versus placebo in patients with psoriatic arthritis (PsA). This post hoc analysis explored relationships between prospectively identified baseline characteristics [poor prognostic factors (PPFs) ] and response to abatacept. Patients were randomized (1:1) to receive subcutaneous abatacept 125 mg weekly or placebo for 24 weeks; those without ≥ 20% improvement in joint counts at Week 16 switched to open-label abatacept. Potential predictors of ACR20 response were identified by treatment arm using multivariate analyses. Likelihood of ACR20 response to abatacept versus placebo was compared in univariate and multivariate analyses in subgroups stratified by the PPF, as defined by EULAR and/or GRAPPA treatment guidelines. Odds ratios (ORs) were generated using logistic regression to identify meaningful differences (OR cut-off: 1.2). 424 patients were randomized and treated (abatacept n = 213; placebo n = 211). In abatacept-treated patients, elevated C-reactive protein (CRP), high Disease Activity Score based on 28 joints (CRP), presence of dactylitis, and ≥ 3 joint erosions were identified as predictors of response (OR > 1.2). In placebo-treated patients, only dactylitis was a potential predictor of response. In the univariate analysis stratified by PPF, ACR20 response was more likely (OR > 1.2) with abatacept versus placebo in patients with baseline PPFs than in those without; multivariate analysis confirmed this finding. Response to abatacept versus placebo is more likely in patients with features indicative of high disease activity and progressive disease; these characteristics are recognized as PPFs in treatment guidelines for PsA.

Tissue adaptation rate in the treatment of Dupuytren contracture.

STUDY DESIGN: Basic research (cross-sectional). INTRODUCTION: Dupuytren disease can cause disabling contractures of the finger joints. After partial fasciectomy, postoperative hand splinting helps to maintain extension range of motion. PURPOSE OF THE STUDY: To measure how the contraction forces of the finger on the splint change over time. METHODS: Subjects who were treated for Dupuytren contracture with partial fasciectomy were invited to participate in this study. Force sensors were placed in their dorsal extension splint, and the applied force was measured continually for several weeks. RESULTS: Eleven subjects (aged 59-75 years) with the metacarpophalangeal (8) or proximal interphalangeal (3) as their most severely affected finger joint participated. Each night, the measured force consistently decreased to reach a plateau after about 3 hour (adaptation time, 2.55; 95% confidence interval, 0.2-31.8 hours). The time to reach this plateau decreased with time after surgery (≈5%/day, P = .0005, R2 = 0.08). DISCUSSION AND CONCLUSIONS: The observed rate of decrease in the measured force indicates a tissue adaptation time of approximately 3 hours.

Novel NOG (p.P42S) mutation causes proximal symphalangism in a four-generation Chinese family.

BACKGROUND: Proximal symphalangism (SYM1; OMIM 185800), also called Cushing's symphalangism, is an infrequent autosomal dominant disease. An SYM1 patient typically features variable fusion of proximal interphalangeal joints in the hands and feet. METHODS: We recruited a four-generation Chinese non-consanguineous family with SYM1. We examined their hands and feet using X-rays to confirm fusion of proximal interphalangeal joints. We evaluated their audiology using standard audiometric procedures and equipment. Then, we identified genetic variants using whole exome sequencing and validated mutations using Sanger sequencing. Mutation pathogenicity was analyzed with bioinformatics. RESULTS: Radiographs revealed proximal-joint fusion of fingers and toes in the patients. Two elderly individuals (II:1 and II:4) exhibited slight hearing loss. Additionally, we detected a novel heterozygous missense mutation in exon 1 of NOG (NM_005450) c.124C > T, p.(Pro42Ser) in all patients. This c.124C > T mutation is highly conserved across multiple species and the p.(Pro42Ser) variation is potentially highly pathogenic. CONCLUSION: Our results suggest that heterozygous c.124C > T, p.(Pro42Ser) in NOG is a novel mutation that causes human SYM1 phenotype.

Methotrexate achieves major cDAPSA response, and improvement in dactylitis and functional status in psoriatic arthritis.

OBJECTIVE: Despite the widespread clinical use of MTX in PsA, data from published randomized controlled studies suggest limited efficacy. The objective of the present study was to document the efficacy of MTX. METHODS: This was an open-label, prospective study of patients satisfying the ClASsification criteria for Psoriatic ARthritis study (CASPAR) criteria for PsA who received MTX in doses of ⩾15 mg/week throughout the follow-up period of 9 months. Disease activity was assessed across various domains by tender and swollen joint count, physician and patient global assessment, DAS-28 ESR, Clinical Disease Activity Index for PsA (cDAPSA), Leeds Dactylitis Instrument basic, Leeds Enthesitis Index (LEI), Psoriasis Area and Severity Index (PASI), Minimal Disease Activity and HAQ (CRD Pune version) at baseline and at 3, 6 and 9 months of follow-up. Response to therapy was assessed by EULAR DAS28 ESR, Disease Activity Index for PsA (cDAPSA) response, HAQ response and PASI75. MTX dose escalation and the use of combination DMARDS were dictated by disease activity. RESULTS: A total of 73 patients were included, with mean (s.d.) age 44 (9.7) years. The mean (s.d.) dose of MTX used was 17.5 (3.8) mg/week. Seven patients received additional DMARDS (LEF/SSZ). At the end of 9 months, significant improvement (P < 0.05) was noted in the tender joint count, swollen joint count, global activity, DAS-28ESR, cDAPSA, Leeds Dactylitis Index basic, LEI, PASI and HAQ. Major cDAPSA response was achieved in 58.9% of patients. EULAR DAS28 moderate and good response was achieved in 74% and 6.8% of patients, respectively. Minimal Disease Activity was achieved in 63% of patients. A PASI75 response and HAQ response was achieved in 67.9% and 65.8% of patients, respectively. CONCLUSION: MTX initiated at ⩾15 mg/week with targeted escalation resulted in significant improvement in the skin, joint, dactylitis, enthesitis and functional domains of PsA.

Distal radius and tibia bone microarchitecture impairment in female patients with diffuse systemic sclerosis.

Radius and tibia bone microarchitecture, analyzed through a high-resolution peripheral quantitative computed tomography, were significantly impaired in female patients with diffuse systemic sclerosis compared with healthy controls. Acroosteolysis, quality of life-grip strength, hand disability, and disease duration were significantly associated with this bone deterioration. INTRODUCTION: The effect of diffuse systemic sclerosis (dSSc) on the bone is not completely understood. The objective of this study was to analyze the volumetric bone mineral density (vBMD), microarchitecture, and biomechanical parameters at the distal radius and tibia using high-resolution peripheral quantitative computed tomography (HR-pQCT, XtremeCT) in female patients with dSSc and identify clinical and laboratory variables associated with these parameters. METHODS: Thirty-eight women with dSSc and 76 healthy controls were submitted to HR-pQCT at the distal radius and tibia. Clinical and laboratory findings, bone mineral density(BMD), nailfold capillaroscopy (NC), total passive range of motion(ROM), and quality of life (health assessment questionnaire-HAQ) were associated with HR-pQCT (Scanco Medical AG, Brüttisellen, Switzerland) parameters. Multiple linear regression models adjusted for clinical and laboratory variables, ROM and HAQ, were performed. RESULTS: Density, microarchitecture, and biomechanical parameters at the distal radius and tibia were significantly impaired in dSSc patients compared with healthy controls (p < 0.001). Multiple linear regression models showed that lower trabecular density (Tb.vBMD) (radius R2 = 0.561, p = 0.002; and tibia R2 = 0.533, p = 0.005), and lower trabecular number (Tb.N) (tibia R2 = 0.533, p = 0.005) were significantly associated with acroosteolysis. Higher trabecular separation (Tb.Sp) was associated with disease duration and higher HAQ-grip strength (radius R2 = 0.489, p = 0.013), while cortical density (Ct.vBMD) was associated with ROM (radius R2 = 0.294, p = 0.002). CONCLUSION: Bone microarchitecture in patients with dSSc, analyzed through HR-pQCT, showed impairment of trabecular and cortical bone at distal radius and tibia. Variables associated with hand involvement (acroosteolysis, quality of life-grip strength, and ROM) and disease duration may be considered prognostic factors of this bone impairment.

A novel treatment for idiopathic knuckle pads with cantharidin-podophylotoxin-salicylic acid.

Knuckle pads are benign subcutaneous nodules that appear most frequently on the small joints of the hands. In children, they are often idiopathic, and no universally effective treatment has been reported. We present the case of an adolescent successfully treated with a combination of topical cantharidin -podophylotoxin -salicylic acid.

A Test for the Clinical Evaluation of the Flexor Digitorum Superficialis of the Fifth Finger.

Physical examination is essential in diagnosing tendinous lesions. This is particularly true of the flexor digitorum superficialis of the little finger (FDS5), which is functionally absent in approximately 30% of the population. The objective of our study was to determine the diagnostic value of 3 clinical tests commonly used to assess the function of this tendon. METHODS: Patients with wounds of the FDS5 were included in this study. Under local or regional anesthesia, 3 described clinical tests were performed to assess the function of the FDS5: (i) the classic test; (ii) Stein's modified test, and (iii) Mecott's modified test. We determined sensitivity, specificity, and predictive values of all such tests. The integrity of the tendon was assessed surgically. Correlation among blinded observers was also established. RESULTS: A total of 28 subjects with a mean age of 28 years (ranging from 5 to 56) participated in this study. The classic test obtained a sensitivity of 100% and a specificity of 72%; Stein's test resulted in a sensitivity of 83% and a specificity of 95%, whereas Mecott's test reached a sensitivity of 100% and a specificity of 95%. CONCLUSIONS: Among the 3 tests described and used in our study, Mecott's modified test proved to be more sensitive and specific than the other two; therefore, we consider this to be the test that should be used in determining the integrity of the FDS5.

The Effect of Extensor Tendon Adhesions on Finger Motion.

PURPOSE: To quantify the amount and pattern of finger range of motion loss at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints with a simulated extensor tendon adhesion at the level of the proximal phalanx or metacarpal. METHODS: In 10 cadaveric specimens, traction sutures were placed in the forearm extensor digitorum communis and flexor digitorum profundus tendons of the middle and ring fingers. Active motion was simulated by suspending weights from the traction sutures via pulleys. The angles of the MCP, PIP, and DIP joints were measured at the position of maximum flexion and extension. Extensor tendon adhesions were simulated alternately at the proximal phalanx and metacarpal levels of the middle and ring fingers, using suture anchors. Repeat measurements were taken using the same amount of force. RESULTS: There was an average total loss of flexion of 38° and of extension of 6° with a proximal phalanx adhesion, with a greater contribution of flexion loss at the PIP joint. The loss of flexion was 17° and of extension was 50° with a metacarpal adhesion, with a loss of extension mostly at the MCP joint. CONCLUSIONS: The results of this study identified clear patterns of motion loss that are associated with isolated simulated adhesions in different locations along the extensor mechanism. The greatest motion loss occurred at the joint immediately distal to the simulated adhesion. CLINICAL RELEVANCE: Although extrapolation of these findings to clinical relevance remains unclear, the ability to predict the level of adhesion by the pattern of motion restriction may allow for a targeted tenolysis procedure. This would reduce the amount of soft tissue dissection required, which in turn, could be expected to reduce the degree of repeat adhesion formation.

Correlations Among Objectively Measured Impairment, Outcome Classification Systems, and Subjectively Perceived Disability After Flexor Tendon Repair.

PURPOSE: Any loss of range of motion of the finger after flexor tendon repair is an impairment of function, but to what extent it causes disability is not properly understood. The aim of this study was to assess the correlation between perceived function (disability) and objectively measured loss of function (impairment), to understand what impairments are meaningful to patients. METHODS: We assessed 49 patients who underwent flexor tendon repair an average of 38 months after repair. We measured the perceived function with the visual analog scale, the 4-step rating scale (poor, fair, good, or excellent), and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. The objective measurement of impairment included active range of motion at each joint, total active motion, grip strength, and 2-point discrimination. We also converted range of motion into 4 categories (poor, fair, good, and excellent) following guidelines from 3 different classification systems (American Society for Surgery of the Hand, Strickland-Glocovac, and revised Strickland). We used Spearman ρ and linear regression to assess the correlation. RESULTS: Active range of motion at the distal interphalangeal joint had a strong correlation and total active range of motion of the finger joints had a moderate correlation with perceived function measured using the visual analog scale and DASH score. Other measured impairments did not correlate with perceived function. Objective classification categories also did not correlate with the patient's own assessment. CONCLUSIONS: Our results validate the use of range of motion and the DASH questionnaire in assessing flexor tendon repairs. Classification of angular measurement according to the tested systems does not reflect the patient's perspective; it limits the precision of the measurement and adds little value to the measurement itself. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Factors Causing Prolonged Postoperative Symptoms Despite Absence of Complications After A1 Pulley Release for Trigger Finger.

PURPOSE: This study aimed to investigate the incidence and prognostic factors for prolonged postoperative symptoms after open A1 pulley release in patients with trigger finger, despite absence of any complications. METHODS: We reviewed 109 patients (78 single-finger involvement, 31 multiple-finger involvement) who underwent open A1 pulley release for trigger finger from 2010 to 2016, with 8 weeks or longer postsurgical follow-up and without postoperative complications. The group had 16 men and 93 women, with mean age of 56 years (range, 21-81 years), and average follow-up period of 24.8 weeks (range, 8.0-127.4 weeks). Prolonged postoperative symptoms were defined as symptoms persisting for longer than 8 weeks after surgery. Factors analyzed for delay in recovery included duration of preoperative symptoms; number of preoperative local corticosteroid injections; preoperative flexion contracture of proximal interphalangeal (PIP) joint; multiplicity of trigger finger lesions; occupation; presence of type 2 diabetes mellitus, other hand disorders like carpal tunnel syndrome, de Quervain disease, or Dupuytren contracture; and fraying or partial tear of the flexor tendon. RESULTS: Twenty-six fingers (19.3%) showed prolonged postoperative symptoms, with mean time until complete relief being 14.0 ± 6.4 weeks (range, 9-34 weeks). Risk factors associated with prolonged postoperative symptoms included duration of preoperative symptoms, preoperative flexion contracture of the PIP joint, and fraying or partial tear of the flexor tendon. CONCLUSIONS: Physicians should consider the duration of preoperative symptoms and preoperative flexion contracture of the PIP joint when deciding timing of surgery for trigger finger patients. In addition, they should explain to patients with a positive history of these factors and in whom flexor tendon injury is found during surgery about the possibility of prolonged postoperative symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Comparison of Percutaneous Reduction and Pin Fixation in Acute and Chronic Pediatric Mallet Fractures.

BACKGROUND: Although pediatric mallet fractures are more common than adult fractures, no techniques have focused on surgical fixation of pediatric mallet fractures. This study aims to describe the technique and results of percutaneous reduction and fixation in acute and chronic pediatric mallet fractures. METHODS: This is a retrospective review of 51 pediatric mallet fractures treated with percutaneous wire fixation from 2007 to 2014; 38 were acute fractures and 13 were chronic (>4 wk from injury). Surgical technique was identical for all fractures: (1) levering the dorsal fragment into its anatomical bed with a percutaneous towel clip; (2) percutanously transfixing the distal interphalangeal joint in slight hyperextension; (3) placing 2 percutaneous kirschner wires, 1 radial and 1 ulnar, from the dorsal epiphyseal fragment to the volar metaphyseal cortex. Outcomes were defined by the Crawford classification. RESULTS: Average age was 14.6 years (range, 11 to 18 y). Mean time from injury to surgery was 16.2 days in the acute group and 50.8 days in the chronic group. Mean joint surface involvement was 50.8% of the articular base with a mean of 2.0 mm of articular gap (acute fractures 1.9 mm, chronic fractures 2.5 mm, P=0.017). Average preoperative extensor lag was 24.6 degrees. Average operative time was 31 minutes for acute fractures and 40 minutes for chronic fractures. Mean length of follow-up was 78.5 days. At final follow-up, all patients healed with an articular gap of 0.2 mm in the acute group and 0.6 mm in the chronic group (P=0.037) with no nonunions or volar subluxations. All patients but 8 (5 acute, 3 chronic) achieved full extension with an average extensor lag of 1.1 degree for the entire cohort. No patient had >10-degree extensor lag at final follow-up. All patients achieved full active flexion of 90 degrees at final follow-up. In the acute group, the Crawford classification was excellent in 87% (33/38), good in 13% (5/38). In the chronic group, results were excellent in 77% (10/13), good in 23% (3/13) (P>0.05). There were no fair or poor outcomes in either group. A clinical dorsal bump was noted in 18% of patients (22% in the acute group, 15% in the chronic group, P>0.05). There were no infections, wire breakages, nail deformities, or unplanned returns to surgery. CONCLUSIONS: This percutaneous surgical technique to treat pediatric mallet fractures achieves favorable clinical and radiographic results with minimal complications, even in chronic fractures. Results are better than reported for adult mallet fractures. LEVEL OF EVIDENCE: Level II.