Fluorinated Tags to Study Protein Conformation and Interactions Using 19F NMR.

The incorporation of fluorine atoms into a biomacromolecule provides a background-free and environmentally sensitive reporter of structure, conformation and interactions using 19F NMR. There are several methods to introduce the 19F reporter - either by synthetic incorporation via solid phase peptide synthesis; by suppressing the incorporation or biosynthesis of a natural amino acid and supplementing the growth media with a fluorinated counterpart during protein expression; and by genetic code expansion to add new amino acids to the amino acid alphabet. This review aims to discuss progress in the field of introducing fluorinated handles into biomolecules for NMR studies by post-translational bioconjugation or 'fluorine-tagging'. We will discuss the range of chemical tagging 'warheads' that have been used, explore the applications of fluorine tags, discuss ways to enhance reporter sensitivity and how the signal to noise ratios can be boosted. Finally, we consider some key challenges of the field and offer some ideas for future directions.

The significance of subjective mechanical symptoms in rotator cuff pathology.

BACKGROUND: The presence of subjective mechanical symptoms, such as clicking or popping, is common in patients presenting for shoulder pain and dysfunction, with unclear clinical significance. The primary objective of this study was to assess whether subjective mechanical symptoms in the affected shoulder were associated with full-thickness rotator cuff tearing in a consecutive, prospective cohort of patients undergoing shoulder magnetic resonance imaging (MRI) for suspected rotator cuff pathology. METHODS: A prospective cohort study was performed of 100 consecutive patients with suspected rotator cuff tendinopathy and/or tearing who underwent shoulder MRI. The presence of subjective shoulder mechanical symptoms, including clicking or popping, was documented prior to MRI. Indications for MRI included weakness on isolated testing of rotator cuff muscle(s) or symptoms refractory to conservative treatment including at least a 6-week course of physical therapy. The primary outcome variable was the presence of full-thickness rotator cuff tearing; secondary outcome variables included any (full-thickness or partial-thickness) rotator cuff tearing and biceps long head subluxation. Radiographic parameters, including critical shoulder angle, Goutallier grade, tear retraction, and tear size were quantified. One patient was lost to follow-up, and 99 patients completed MRI imaging. RESULTS: In our cohort, 60% of patients reported subjective mechanical symptoms in the affected shoulder. Full-thickness rotator cuff tearing was identified in 42% of patients, any rotator cuff tearing in 69% of patients, and biceps long head subluxation in 14% of patients. Subjective mechanical symptoms were not associated with full-thickness rotator cuff tearing, any rotator cuff tearing, biceps long head subluxation, critical shoulder angle, Goutallier grade, tear size, or tear retraction. Older age was associated with full-thickness and any rotator cuff tearing. As a diagnostic test for full-thickness rotator cuff tearing, subjective shoulder mechanical symptoms has a sensitivity of 64%, a specificity of 44%, and Youden's index of 0.08, consistent with poor diagnostic accuracy. CONCLUSIONS: Subjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. Patients may be reassured that a sensation of clicking or popping alone does not necessarily entail structural shoulder derangement.

5,10,15,20-Tetrakis(pentafluorophenyl)porphyrin as a Functional Platform for Peptide Stapling and Multicyclisation.

Polyfluorinated aromatic reagents readily react with thiolates via nucleophilic aromatic substitution (SN Ar) and provide excellent scaffolds for peptide cyclisation. Here we report a robust and versatile platform for peptide stapling and multicyclisation templated by 5,10,15,20-tetrakis(pentafluorophenyl)porphyrin, opening the door to the next generation of functional scaffolds for 3D peptide architectures. We demonstrate that stapling and multicyclisation occurs with a range of non-protected peptides under peptide-compatible conditions, exhibiting chemoselectivity and wide-applicability. Peptides containing two cysteine residues are readily stapled, and the remaining perfluoroaryl groups permit the introduction of a second peptide in a modular fashion to access bicyclic peptides. Similarly, peptides with more than two cysteine residues can afford multicyclic products containing up to three peptide 'loops'. Finally, we demonstrate that a porphyrin-templated stapled peptide containing the Skin Penetrating and Cell Entering (SPACE) peptide affords a skin cell penetrating conjugate with intrinsic fluorescence.

Probing Peptidylprolyl Bond cis/trans Status Using Distal 19 F NMR Reporters.

A method for measuring peptidylprolyl bond cis-trans conformational status in peptide models is described, using 4-fluorophenylalanine (4FPhe) as a distal reporter for 19 F NMR. The %cis-Pro population was measured for peptides of the general structure Ac-X-Pro-Z-Ala-Ala-4FPhe (X and Z are proteinogenic amino acids) at pH 7.4, and provided conformational populations consistent with literature values obtained by more complex methods. This approach was applied to probe the prolyl bond status in pentapeptide models of the intrinsically disordered C-terminal region of α-synuclein, which mirrored the preferences in the Ac-X-Pro-Z-Ala-4FPhe models. Advantageously, the 19 F reporter group does not need to be adjacent to or attached to proline to provide quantifiable signals and distal 4-fluorophenylalanines can be placed so as not to influence prolyl bond conformation. Finally, we demonstrated that the prolyl bond status is not significantly affected by pH when there are ionisable amino acid residues at the carboxyl side of proline, which makes 19 F NMR an invaluable tool with which to study proline isomerism at a range of pHs and in different solvents and buffers.

The Environmental Impact of Open Versus Endoscopic Carpal Tunnel Release.

PURPOSE: The environmental impact of common ambulatory hand surgeries has been an area of growing interest in recent years. There were 2 objectives of this study: (1) to quantify the carbon footprint of carpal tunnel surgery and its principal driving components; and (2) to compare the carbon footprints of open carpal tunnel release (oCTR) and endoscopic carpal tunnel release (eCTR). METHODS: We performed a life cycle assessment to quantify the environmental impacts of 2 surgical procedures: oCTR and eCTR. Patients were retrospectively identified by querying the Mass General Brigham institutional billing database. Fourteen oCTR procedures and 14 eCTR procedures in 28 patients were included in the life cycle assessment. The boundaries of the life cycle assessment were the start and end times of the procedures. The environmental impacts were estimated using the carbon footprint, expressed in the equivalent mass of carbon dioxide released into the atmosphere (kgCO2-eq). The facility-related, processing-related, solid waste-related, and total kgCO2-eq were calculated. RESULTS: The average carbon footprint of carpal tunnel release was 83.1 kgCO2-eq and was dominated by processing-related and facilities-related factors. The average carbon footprint of eCTR (106.5 kgCO2-eq) was significantly greater than that of oCTR (59.6 kgCO2-eq). CONCLUSIONS: Endoscopic carpal tunnel release leaves a greater carbon footprint than oCTR, and its environmental impact is dominated by facility-related and central processing-related factors. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses IV.

Factors Associated With Implant Removal Following Plate-and-Screw Fixation of Isolated Metacarpal Fractures.

PURPOSE: The incidence of and associated risk factors for implant removal following the plate-and-screw fixation of metacarpal shaft fractures have not been well described. The primary objective of our study was to identify implant-related radiographic parameters associated with implant removal in patients treated with the plate-and-screw fixation of isolated, displaced metacarpal fractures at 2 years of follow-up. The secondary objective of our study was to identify patient-related factors associated with implant removal. METHODS: A retrospective study of all patients who underwent open treatment of a metacarpal fracture with a plate-and-screw construct from January 1, 2000, to April 30, 2019, at 2 level-1 trauma centers was conducted. After the application of exclusion criteria, we identified 138 patients with a single isolated metacarpal fracture of a nonthumb digit treated with open reduction and internal fixation using a plate-and-screw construct. Our study endpoint was the removal of the plate-and-screw construct or a minimum of 2 years of follow-up without the removal of the hardware. Twenty-three patients achieved our study endpoint as determined using their electronic medical records, and 58 additional patients were reached via telephone to confirm their implant removal status. A bivariate analysis was used to screen for factors associated with implant removal, and variables significant in the bivariate screen were included in a multivariable stepwise logistic regression model. RESULTS: Twenty-three out of 81 patients (28%) in our final cohort underwent implant removal by the final follow-up visit. In the logistic regression analysis, the distance between the plate and metacarpophalangeal joint, the distance between the plate and carpometacarpal joint, and active smoking were independently associated with implant removal. CONCLUSIONS: The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal. Patients may be counseled about the higher risk of implant removal when periarticular metacarpal plating is performed. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

The Impact of Resident Involvement on Outcomes and Costs in Elective Hand and Upper Extremity Surgery.

PURPOSE: The purpose of this study was to assess the impact of resident involvement on periprocedural outcomes and costs after common procedures performed at an academic hand surgical practice. METHODS: A retrospective review was performed in all patients undergoing 7 common elective upper extremity procedures between January 2008 and December 2018: carpal tunnel release, distal radius open reduction and internal fixation (ORIF), trigger finger release, thumb carpometacarpal arthroplasty, phalanx closed reduction and percutaneous pinning, cubital tunnel release, and olecranon ORIF. The medical record was reviewed to determine the impact of surgical assistants (resident, fellow, or physician assistant) on periprocedural outcomes, periprocedural costs, and 1-year postoperative outcomes. The involvement of surgical trainees operating under direct supervision was compared with the entire operation performed by the attending surgeon with a physician assistant present. RESULTS: A total of 396 procedures met the inclusion criteria. Analysis of the whole study sample revealed low rates of intraoperative complications, wound complications, medical complications, readmissions, and mortality. Subgroup analysis of carpal tunnel releases revealed significantly greater tourniquet times for residents compared with physician assistants (7 ± 2 min, 6 ± 1 min), as well as longer overall operating room times for residents compared to fellows or physician assistants (17 ± 5 min, 13 ± 3 min, 12 ± 3 min). Operating room times for distal radius ORIF were significantly greater among residents compared to fellows or physician assistants (68 ± 19 min, 57 ± 17 min, 56 ± 14 min). There were no differences in any other perioperative metrics or periprocedural costs for the trigger finger release or cubital tunnel release cohorts. CONCLUSIONS: Resident involvement in select upper extremity procedures can lengthen operative times but does not have an impact on blood loss or operating room costs. CLINICAL RELEVANCE: Surgeons should be aware that having a resident assistant slightly increases operative times in elective hand surgery.

Characteristics and outcomes of patients who undergo fasciotomies for upper arm compartment syndrome.

PURPOSE: Describe the demographic, injury-related, treatment-related, and outcome-related characteristics of patients who undergo fasciotomies for acute upper arm compartment syndrome (ACS). METHODS: From January 1, 2006, to June 30, 2015, 438 patients with a diagnosis code of upper extremity (including hand, forearm, arm, and shoulder) compartment syndrome at two tertiary care centers were identified. Of those patients, 423 were excluded for a diagnosis other than upper arm ACS or incomplete documentation. A final cohort of 15 adult patients with acute upper arm compartment syndrome treated with fasciotomy was included. The electronic medical record for patient-related variables, lab data, mechanism of injury, presence of additional injuries, and treatment-related variables were reviewed. RESULTS: The mean age of our cohort was 52 years, and 73% were male. The most common mechanisms of injury were blunt trauma (20%), vascular injury (20%), oncologic resection (13%), and infection related to intravenous drug use (13%). Humerus fractures and biceps tendon ruptures were associated with 13 and 27% of the cases, respectively. More than two-thirds of the patients had elevated international normalized ratios (INR). While 27% of cases underwent fasciotomy within 6 h after injury, seven patients (47%) underwent fasciotomy more than 24 h after injury. Six patients had no major deficits, while 7 patients had long-term deficits. CONCLUSION: Upper arm ACS is a potentially devastating condition that can be seen after blunt trauma, vascular injury, oncologic resection, and intravenous drug use. Clinicians should have high suspicion in cases of elevated INR and biceps tendon rupture.

Upper extremity fractures due to intimate partner violence versus accidental causes.

PURPOSE: The purpose of this study is to evaluate the prevalence of intimate partner violence (IPV)-related upper extremity fractures (UEF) in women presenting to US emergency departments (ED) and compare their anatomic location to those due to accidental falls or strikes. METHODS: An Institutional Review Board exempt, retrospective review of prospectively collected data was performed using the National Electronic Injury Surveillance System's All Injury Program data from 2005 through 2015 for all UEF sustained in women 15 to 54 years old. Injuries based on reported IPV versus accidental falls or strikes were analyzed accounting for the weighted, stratified nature of the data. RESULTS: IPV-related UEF represented 1.7% of all UEF and 27.2% of all IPV fractures. The finger was the most common fracture site in IPV (34.3%) and accidental striking (53.3%) but accounted for only 10% of fall-related UEF. There was a higher proportion of shoulder fractures in IPV (9.2%) compared to accidental falls (7.4%) or strikes (2.9%). The odds of a finger fracture were 4.32 times greater in IPV than falling and of a shoulder fracture were 3.65 greater in IPV than accidental striking (p < 0.0001). CONCLUSIONS: While the finger is the most common site for IPV UEF, it is also the most common location for accidental striking. A lower proportion of finger fractures in fall and of shoulder/forearm fractures in accidental striking should prompt the radiologist to discuss the possibility of IPV with the ED physician in any woman presenting with a finger fracture due to fall and a shoulder/forearm fracture with a vague history of accidental striking.

Upper extremity injuries in the victims of intimate partner violence.

OBJECTIVES: To recognize most common patterns of upper extremity (UE) injuries in victims of Intimate Partner Violence (IPV). METHODS: Radiological review of 308 patients who reported physical IPV at our institution from January 2013 to June 2018, identified 55 patients with 88 unique UE injuries. Demographic data and injury patterns and associations were collected from the electronic medical records. RESULTS: The cohort included 49 females and 6 males (age 19-63, mean 38). At the time of injury, IPV was reported in 15/88 (17%) and IPV screening was documented for 22/88 (25%) injuries. There were 46 fractures, 8 dislocations or subluxations, and 34 isolated soft tissue injuries, most commonly involving the hand (56/88). Fractures most commonly involved the fingers (21/46, 46%) and the 5th digit (8/27, 30%). Medial UE fractures (5th digit, 4th digit) constituted 44% of hand and finger fractures (12/27) and 26% of all fractures (12/46). Comminuted and displaced fractures were rare (8/46, 17%). Head and face injuries were the most common concomitant injuries (9/22, 41%) and subsequent injuries (21/61, 35%). Of 12 patients with recurrent UE injuries, 6 had recurrent injuries of the same hand. Five of 6 non-acute fractures (83%) were of the hand. CONCLUSIONS: Hand and finger injuries are the most common UE injuries in patients with IPV, with finger being the most common site and medial hand the most common region of fracture. Repeated injuries involving the same site and a combination of medial hand and head or face injuries could indicate IPV. KEY POINTS: • Upper extremity injuries in victims of intimate partner violence are most commonly seen in the hand and fingers. • Fingers are the most common site of fracture and the medial hand is the most common region of fracture in the upper extremity in victims of intimate partner violence. • In intimate partner violence victims with upper extremity injuries, concomitant injuries and subsequent injuries are most commonly seen in the head and neck region.

Correlation and responsiveness of global health, upper extremity-specific, and shoulder-specific functional outcome measures following reverse total shoulder arthroplasty for proximal humerus fracture.

PURPOSE: Reverse total shoulder arthroplasty (rTSA) is effective and increasingly utilized for the management of proximal humerus fracture (PHF). However, the optimal patient-reported outcome metrics (PROMs) for the evaluation of patient outcomes after this surgery are unclear. We investigated the correlation among global, upper extremity-specific, and shoulder-specific PROMs in patients undergoing rTSA for PHF as well as the responsiveness of these PROMs as assessed by floor and ceiling effects. We hypothesized that patients' post-operative outcome would be best reflected by a combination of these metrics. METHODS: Thirty patients with a history of rTSA for ipsilateral PHF filled out the following outcomes questionnaires at a minimum of 3 years post-op: EQ-5D, EQ-5D VAS, PROMIS physical function, DASH, SSV, SPADI, and ASES. Correlation between metrics was assessed using the Spearman correlation coefficient. Responsiveness was assessed by comparing the proportion of patients reaching floor or ceiling values using McNemar's test. RESULTS: Global health metrics (EQ-5D and PROMIS physical function) were strongly correlated with the upper extremity-specific metric (DASH). Shoulder-specific outcomes (SPADI, ASES, and ASES) were moderately correlated with both the global metrics and DASH. There was no significant difference between PROMs with regards to floor and ceiling effects. CONCLUSIONS: The DASH score has been shown to be valid and responsive for shoulder interventions, and our data demonstrate that it correlates strongly with overall quality of life. Shoulder-specific metrics are valid and responsive for shoulder interventions but correlate less with global quality of life. An optimal PROM strategy in rTSA for PHF might involve both DASH and a shoulder-specific score. Based on our assessment of floor and ceiling effects, none of these metrics should be excluded for poor responsiveness.

Delayed Referral for Adult Traumatic Brachial Plexus Injuries.

PURPOSE: The treatment of traumatic brachial plexus injury (BPI) is time-sensitive, and early nerve reconstruction is associated with superior nerve recovery. The objective of this study was to determine the rate of delayed referral to our centers for traumatic BPI, identifiable causes of delayed referral, and factors associated with delayed referral to a brachial plexus surgeon. METHODS: We identified 84 patients with traumatic BPI referred to and evaluated by brachial plexus surgeons at 2 tertiary care referral centers from 2015 to 2019. Delayed referral was defined as more than 3 months from the date of injury to the date of initial evaluation by a brachial plexus surgeon. Causes of delayed referral were identified by review of the medical record. Bivariate analysis and multivariable logistic regression were used to identify factors associated with delayed referral. RESULTS: Mean age of the 84 patients in the study was 45 years; 69% were male. The most common pattern of BPI was global palsy (39%), followed by upper-trunk palsy (23%) and infraclavicular palsy (15%). Median time from injury to surgical evaluation was 2 months (interquartile range, 2-4 months). Thirty-seven patients had a delayed referral (44%). Multivariable logistic regression analysis showed that the hospital to which the patient was referred, Medicare insurance, and motorcycle accident as the mechanism of injury were associated with a delayed referral. CONCLUSIONS: Nearly half of traumatic BPI patients evaluated at 2 tertiary referral centers in a large metropolitan area in the United States presented in a delayed time frame. Both modifiable and nonmodifiable associations with delayed referral were identified. Patients with Medicare insurance had increased odds of delayed referral. CLINICAL RELEVANCE: Establishment of multidisciplinary BPI specialty centers, outreach to local and regional hospitals, and development of referral algorithms and pathways may improve timeliness of referrals.

Primary Mucinous Adenocarcinoma of the Urinary Bladder: A Rare Entity.

Adenocarcinoma constitutes around 0.5 to 2% of all neoplastic lesions of the urinary bladder, out of which, the mucinous variant is seen on rare occasions. Intestinal metaplasia resulting from nephrolithiasis, chronic inflammation and hydronephrosis could be the precursor lesion. Bladder exstrophy and remnants of the urachus are considered as other possible risk factors. The tumour prefers patients who are over 50 years. Hematuria, difficult voiding and suprapubic pain are the most common presenting symptoms. The tumour has a very bad prognosis and is poorly responsive to chemo and radiotherapy and hence surgery is the treatment of choice. Hence early diagnosis is of paramount importance. While managing adenocarcinoma of the bladder, it is important to rule out any possibility of a metastatic lesion that could have come from other organs where mucinous adenocarcinoma is more common.

L'adénocarcinome constitue environ 0,5 à 2 % de toutes les lésions néoplasiques de la vessie, dont la variante mucineuse est rarement observée. La métaplasie intestinale résultant d'une néphrolithiase, d'une inflammation chronique et d'une hydronéphrose pourrait être la lésion précurseur. L'exstrophie de la vessie et les restes de l'ouraque sont considérés comme d'autres facteurs de risque possibles. La tumeur préfère les patients de plus de 50 ans. Une hématurie, une miction difficile et des douleurs sus-pubiennes sont les symptômes les plus fréquents. La tumeur a un très mauvais pronostic et répond mal à la chimiothérapie et à la radiothérapie et la chirurgie est donc le traitement de choix. Par conséquent, un diagnostic précoce est d'une importance primordiale. Lors de la prise en charge d'un adénocarcinome de la vessie, il est important d'écarter toute possibilité de lésion métastatique qui pourrait provenir d'autres organes où l'adénocarcinome mucineux est plus fréquent. WAJM 2021 ; 38(6) : 604­606.

Outcomes Measurement in Global Hand Surgery.

The global burden of musculoskeletal trauma is high. There is a need to improve access to safe, high-quality surgery in many low- and middle-income countries (LMICs). Numerous initiatives have taken aim at solving this underlying shortage in surgical care, including mission trips, academic programs, and international collaborations. However, much work remains to be done in LMICs compared with high-income countries (HICs). In HICs, the field of hand surgery has grown partially owing to the rigorous application of clinical research to examine outcomes and determine best practices. Patient-reported outcome measures (PROMs) have a key role as a valid patient-centered method of capturing symptoms and well-being. They have substantial promise in LMICs to understand patient symptom severity and quality of life better, monitor treatment success or failure, determine cost-effectiveness of procedures, and guide capacity building. Contextually appropriate PROMs can improve routine follow-up in LMICs and advance the practice and study of hand surgery worldwide.

Opioid Prescribing Patterns of Orthopedic Surgery Residents After Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: In many academic medical centers, resident physicians typically write initial opioid prescriptions, but little is known about their prescribing practices. We hypothesized that lower resident postgraduate year, residency-training program, and noncompletion of an opioid prescribing training would be factors associated with increased opioid prescribing by orthopedic residents after open reduction and internal fixation of distal radius fractures. METHODS: A survey was administered to all 135 residents from 4 orthopedic residency programs in a state located in the northeastern United States between August 2017 and November 2017. Respondents were asked to indicate the initial analgesia (quantity and duration) they would prescribe for a younger and older, otherwise healthy, opiate-naïve female patient after open reduction and internal fixation of a distal radius fracture. We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MME) and number of days supplied. Three different measures of overprescribing were assessed: prescribing over 150 MME, 225 MME, or 7 days of opioids. RESULTS: The response rate was 63% (85 of 135 residents). Of all respondents, 36.5% of residents reported completion of an opioid training in the past. In terms of overprescribing by duration, 19% of residents prescribed more than 7 days of opioids. For overprescribing by quantity, 36% to 59% (depending on patient age) of residents prescribed more than 20 tablets of 5 mg oxycodone (150 MME) and 16% to 25% (depending on patient age) prescribed more than 30 tablets of 5 mg oxycodone (225 MME). In comparison with junior residents, senior residents were more likely to prescribe over 225 MME. CONCLUSIONS: After open reduction and internal fixation of distal radius fractures, 19% of orthopedic surgery residents would prescribe more than 7 days of prescription opioids, which is beyond the state law maximum. In addition, we found that less than half of residents had participated in an opioid training program. Our results highlight the need for continued resident guidance when prescribing. Enrollment in opioid prescribing training programs that have been shown to decrease prescribed opioid quantities while still effectively managing patient pain is probably important. CLINICAL RELEVANCE: This study describes the opioid prescribing practices and prior training of orthopedic residents. It highlights an opportunity for increased involvement in educational programs on opioid prescribing that better align with published recommendations/guidelines.

Diagnosis and treatment of acute extremity compartment syndrome.

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

Skin surgery, an evidence-based update: meeting report.

The Evidence Based Update on Skin Surgery was held in Nottingham in May 2015. The meeting featured presentations on new diagnostic techniques, trials in development, discussions of recently published trials, and a question and answer session with an expert panel. This report aims to summarize the presentations and discussions from the day.

Traumatic Finger Injuries: What the Orthopedic Surgeon Wants to Know.

Traumatic finger injuries account for a substantial number of emergency visits every year. Imaging plays an important role in diagnosis and in directing management of these injuries. Although many injuries can be managed conservatively, some require more invasive interventions to prevent complications and loss of function. Accurate diagnosis of finger injuries can often be difficult, given the complicated soft-tissue anatomy of the hand and the diverse spectrum of injuries that can occur. To best serve the patient and the treating physician, radiologists must have a working knowledge of finger anatomy, the wide array of injury patterns that can occur, the characteristic imaging findings of different finger injuries, and the most appropriate treatment options for each type of injury. This article details the intricate anatomy of the hand as it relates to common finger injuries, illustrates the imaging findings of a range of injuries, presents optimal imaging modalities and imaging parameters for the diagnosis of different injury types, and addresses which findings have important management implications for the patient and the orthopedic surgeon. With this fund of knowledge, radiologists will be able to recommend the most appropriate imaging studies, make accurate diagnoses, convey clinically relevant imaging findings to the referring physician, and suggest appropriate follow-up examinations. In this way, the radiologist will help improve patient care and outcomes. Online supplemental material is available for this article. (©)RSNA, 2016.

Two patients with Ehlers-Danlos syndrome type VIII with unexpected hoarseness.

Ehlers-Danlos syndrome (EDS) encompasses a genetically and clinically heterogeneous group of connective tissue disorders, characterized by joint hypermobility, skin hyperextensibility and tissue fragility. It is a rare condition, and inheritance is either autosomal dominant or recessive. Previously grouped into 11 different subtypes, with increasing knowledge of the underlying molecular defects, it was reclassified in 1997 into 6 major groups, with type VIII excluded from this classification. Type VIII EDS is a very rare subtype, characterized by severe, early-onset periodontitis, skin fragility and abnormal scarring. Voice abnormalities have occasionally been described in other forms of the condition, and may be due to defects in the collagen of the vocal ligament. We report two cases of patients with EDS type VIII and hoarseness.