Diagnosis and treatment of flexor tendon injuries of the hand: what the radiologist needs to know.

This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion.

Evaluation of Ulnar Sided Wrist Pain.

Ulnar sided wrist pain often presents a diagnostic challenge. Creating a meaningful differential diagnosis is possible with a detailed history and systematic physical exam using provocative maneuvers. Targeted imaging studies can allow for further narrowing of the differential and ultimate diagnosis.

Perilunate Dislocations: Current Treatment Options.

➢: Approximately 25% of all patients who sustain perilunate dislocations present in a delayed fashion. ➢: While management of acute injuries is relatively well-described, treatment of chronic injuries can be complex and there is a paucity of scientific evidence to guide management. ➢: Treatment options include open reduction internal fixation, proximal row carpectomy, scaphoid or lunate excision with or without arthrodesis, and total wrist arthrodesis, although indications vary based on chronicity of injury and patient factors. ➢: The purpose of this article was to determine the quality of evidence supporting surgical options for the treatment of these injuries.

Nerve Imaging in the Wrist.

Neuropathic symptoms involving the wrist are a common clinical presentation that can be due to a variety of causes. Imaging plays a key role in differentiating distal nerve lesions in the wrist from more proximal nerve abnormalities such as a cervical radiculopathy or brachial plexopathy. Imaging complements electrodiagnostic testing by helping define the specific lesion site and by providing anatomical information to guide surgical planning. This article reviews nerve anatomy, normal and abnormal findings on ultrasonography and magnetic resonance imaging, and common and uncommon causes of neuropathy.

Penlight versus Smartphone: Diagnostic Efficacy of Transillumination.

Background: The purpose of this study was to compare the diagnostic accuracy of a smartphone flashlight to a conventional penlight with regards to transillumination of simulated soft tissue masses of the hand and wrist. Methods: Eight participants performed transillumination assessments in a fresh frozen cadaver upper extremity model. Spheres measuring 9.5 mm were used to simulate fluid-filled or solid soft tissue masses. Two spheres were placed on the volar aspect and two on the dorsal aspect of the wrist. These were then evaluated with either a smartphone flashlight or penlight. Participants noted whether each sphere did or did not transilluminate. Each participant performed two evaluations at an interval of 3 weeks. Results: The overall sensitivity, specificity and accuracy of the smartphone were 100%, 44% and 72%, respectively. The overall sensitivity, specificity and accuracy of the penlight were 100%, 75% and 88%, respectively. The difference in accuracy between the smartphone group and penlight group was statistically significant (p = 0.029). The kappa value, indicating intra-observer agreement, for the smartphone group and penlight group was 0.76 and 0.76, respectively. Conclusion: In conclusion, transillumination with a penlight is a viable adjunct to the examination of soft tissue masses of the hand and wrist. The use of a smartphone flashlight, while convenient, is less accurate than a penlight and can lead the examiners to misinterpret the composition of soft tissue masses. Level of Evidence: Level IV (Diagnostic).

Imaging Evaluation of Medial and Lateral Elbow Pain: Acute and Chronic Tendon Injuries of the Humeral Epicondyles.

Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.

Musculoskeletal Ultrasonography of the Extremities: Clinical and Ultrasonographic Correlation.

Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal injuries. It can be a useful imaging modality for clinical correlation of physical examination findings as well as an aid for image-guided procedures. Understanding the settings in which it is a helpful adjunct will have implications on efficiency and cost utility. The objectives of this chapter are to provide a background of ultrasonography as a musculoskeletal imaging modality, provide clinical correlation for ultrasonographic findings for common upper extremity pathology, review the diagnostic efficacy of ultrasonography for image-guided procedures, and provide insight into the cost utility of ultrasonography guidance for therapeutic injections.

Necrotizing Infections of the Hand and Wrist: Diagnosis and Treatment Options.

Necrotizing infections of the hand and wrist are important clinical entities because of their rapidly progressive and potentially lethal nature. These infections encompass a spectrum of diseases with overlapping signs and symptoms, which can be subtle and nonspecific. If the brief prodromal period of these infections goes unrecognized, a local area of devitalized tissue can evolve into fulminant infection, multiorgan failure, and potentially death. Early recognition and treatment including administration of broad-spectrum antibiotics and surgical débridement are paramount to improving patient outcomes.

Irreducible Galeazzi Fracture-Dislocations.

BACKGROUND: Fractures of the radial shaft with disruption of the distal radial ulnar joint (DRUJ) or Galeazzi fractures are treated with reduction of the radius followed by stability assessment of the DRUJ. In rare instances, the reduction of the DRUJ is blocked by interposed structures requiring open reduction of this joint. The purpose of this study is to review all cases of irreducible Galeazzi fracture-dislocations reported in the literature to offer guidelines in the diagnosis and management of this rare injury. METHODS: A search of the MEDLINE database, OVID database, and PubMed database was employed using the terms "Galeazzi" and "fracture." Of the 124 articles the search produced, a total of 12 articles and 17 cases of irreducible Galeazzi fracture-dislocations were found. RESULTS: The age range was 16 to 64 years (mean = 25 years). A high-energy mechanism of injury was the root cause in all cases. More than half of the irreducible DRUJ dislocations were not identified intraoperatively. In a dorsally dislocated DRUJ, a block to reduction in most cases (92.3%) was secondary to entrapment of one or more extensor tendons including the extensor carpi ulnaris, extensor digiti minimi, and extensor digitorum communis, with the remaining cases blocked by fracture fragments. Irreducible volar dislocations due to entrapment of the ulnar head occurred in 17.6% of cases with no tendon entrapment noted. CONCLUSIONS: In the presence of a Galeazzi fracture, a reduced/stable DRUJ needs to be critically assessed as more than half of irreducible DRUJs in a Galeazzi fracture-dislocation were missed either pre- or intraoperatively.

Obesity Is Not a Predictor of Complications in Upper Extremity Surgery.

BACKGROUND: Obesity is an often-cited cause of surgical morbidity. As a result, many institutions have required screening prior to "clearing" obese individuals for surgery. However, it remains unclear whether such testing is warranted for obese patients prior to upper extremity procedures. This study reviews surgical outcomes to determine if obesity does predict operative morbidity following upper extremity surgery. METHODS: The National Surgical Quality Improvement Program was queried for 18 Current Procedural Terminology codes, representing upper extremity fracture and arthroplasty procedures. Patients' body mass index (BMI) and medical histories were examined as predictors for postoperative complications. Both individual and combined incidences of complications were compared between patients stratified as normal-weight (BMI < 30); obese (BMI 30-40); and morbidly obese (BMI> 40). RESULTS: A total of 8,477 patients were identified over the 5-year study period; 5,303 had a BMI <30, 2,565 a BMI of 30 to 40 and 585 a BMI >40. With the exception of postoperative blood transfusions, there were no significant increases in the incidence rates of any complication event as a function of BMI class. The overall incidence of complications was 2.70 % for BMI <30; 2.74 % for BMI 30 to 40; and 1.54 % for BMI >40. CONCLUSIONS: Obesity is not a reliable predictor of complications following upper extremity surgery. Thus, requiring preoperative screening for obese patients may constitute an unnecessary burden on medical resources. Further study is needed to identify specific demographics that might serve as more accurate predictors of poor outcomes in obese patients undergoing surgery of the upper extremity.