Boutonniere Versus Pseudoboutonniere Deformities: Pathoanatomy, Diagnosis, and Treatment.

Finger injuries involving the proximal interphalangeal (PIP) joint are common, particularly among athletes. Injury severity is often underappreciated at initial presentation and may be dismissed broadly as a "jammed finger" injury. Delayed diagnosis and treatment of certain injuries can have an important impact on the patient's chance of regaining full function. Central slip and PIP volar plate injuries are frequently encountered injuries that, if left untreated, can lead to the permanent loss of function of the proximal interphalangeal joint. Despite the differing mechanisms of these 2 pathologies, volar plate hyperextension injuries often present with a PIP joint flexion contracture and mild distal interphalangeal joint hyperextension deformity. This is similar to a boutonniere deformity seen after an injury to the central slip, and thus, has been referred to as a "pseudo-boutonnière" deformity. Distinguishing these 2 diagnoses is important, as treatment differs, and highlights the importance of thoroughly understanding the anatomy and relevant clinical applications when evaluating PIP joint injuries.

Distal Radius Physeal Bar and Ulnar Overgrowth: Indications for Treatment.

BACKGROUND: Distal radius physeal bar with associated growth arrest can occur because of fractures, ischemia, infection, radiation, tumor, blood dyscrasias, and repetitive stress injuries. The age of the patient as well as the size, shape, and location of the bony bridge determines the deformity and associated pathology that will develop. METHODS: A search of the English literature was performed using PubMed and multiple search terms to identify manuscripts dealing with the evaluation and treatment of distal radius physeal bars and ulnar overgrowth. Single case reports and level V studies were excluded. RESULTS: Manuscripts evaluating distal radial physeal bars and their management were identified. A growth discrepancy between the radius and ulna can lead to distal radioulnar joint instability, ulnar impaction, and degenerative changes in the carpus and triangular fibrocartilage complex. Advanced imaging aids in the evaluation and mapping of a physeal bar. Treatment options for distal radius physeal bars include observation, bar resection±interposition, epiphysiodeses of the ulna±completion epiphysiodesis of the radius, ulnar shortening osteotomy±diagnostic arthroscopy to manage associated triangular fibrocartilage complex pathology, radius osteotomy, and distraction osteogenesis. CONCLUSIONS: Decision-making when presented with a distal radius physeal bar is multifactorial and should incorporate the age and remaining growth potential of the patient, the size and location of the bar, and patient and family expectations.

Optimising the conservative management of closed tendinous mallet finger injury.

Mallet finger injuries are a common presentation in the emergency department. These injuries result from a forced flexion at the distal interphalangeal joint (DIPJ) that causes extensor tendon disruption, and possibly bone avulsion, at the base of the distal phalanx. This article describes the anatomy, mechanisms, classification and assessment of mallet finger injury. It reviews different types of splints used in the conservative management of closed tendinous mallet finger injury and discusses the latest evidence regarding immobilisation methods and treatment duration. Maintaining the DIPJ in extension during treatment is essential, so the article stresses the importance of patient adherence to treatment.

Atypical Chronic Inflammatory ANCA-Positive Deforming Arthritis After Cocaine-Levamisole Exposure.

BACKGROUND/OBJECTIVE: Immunostimulatory drugs including immune checkpoint inhibitors and levamisole can induce inflammatory disease including vasculitis, rashes, tissue necrosis, and arthritis. METHODS: This prospective cohort study determined the 5-year outcomes of cocaine-levamisole-induced inflammatory disease as to outcomes and survival. Thirty-one consecutive cocaine-levamisole autoimmune patients and 45 primary vasculitis patients were characterized as to clinical differentiating features, antineutrophil cytoplasmic antibody (ANCA) status, treatment, the presence of acute and chronic arthritis, and 5-year outcome. RESULTS: Seventy-one percent (22/31) of cocaine-levamisole vasculopathy cases were ANCA positive (86% p-ANCA and 14% c-ANCA), whereas 53% (23/45) of the primary vasculitis were ANCA positive (p = 0.04). The ANCA-positive cocaine-levamisole cohort at onset were characterized by younger age (45 ± 12 vs 53 ± 14 years, p = 0.04), superficial skin necrosis (82% vs 54%, p = 0.036), depressed complement C3 (27% vs 4%, p = 0.33), antiphospholipid antibodies (50% vs 4%, p < 0.001), neutropenia (18% vs 0%, p = 0.044), and elevated antimyeloperoxidase (MPO) antibody levels (100% vs 67%, p < 0.001). Chronic cocaine-levamisole disease was characterized by severe cicatrical deformities of the face and extremities (45.5% vs 8.3%, p = 0.005). Arthralgias (71% vs 82%, p = 0.19) and acute arthritis (33% vs 32%, p = 0.25) were similar between the 2 groups. However, a substantial proportion cocaine-levamisole-induced autoimmune patients (18% vs 0%, p = 0.045) developed a chronic deforming inflammatory arthritis that was rheumatoid factor, anti-cyclic-citrillinated antibody antibody, and HLA-B27 negative, but p-ANCA-and MPO antibody positive. CONCLUSIONS: Patients exposed to cocaine-levamisole may develop serious chronic sequelae including cicatrical cutaneous and facial deformities and an atypical seronegative, p-ANCA and MPO antibody-positive, HLA-B27-negative chronic deforming inflammatory arthritis.

Effect of Distal Ulna Osteochondroma Excision and Distal Ulnar Tether Release on Forearm Deformity in Preadolescent Patients With Multiple Hereditary Exostosis.

BACKGROUND: Multiple hereditary exostosis is a benign condition that can lead to significant forearm deformity secondary to physeal disturbances. As the child grows, the deformity can worsen as relative shortening of the ulna causes tethering, which may lead to increased radial articular angle, carpal slippage, and radial bowing, over time this tethering can also result in radial head subluxation or frank dislocation. Worsening of forearm deformities often require corrective reconstructive osteotomies to improve anatomic alignment and function. The purpose of this study is to evaluate the effectiveness of osteochondroma excision and distal ulnar tether release on clinical function, radiographic anatomic forearm alignment, and need for future corrective osteotomies. METHODS: The authors reviewed a retrospective cohort of preadolescent patients who underwent distal ulna osteochondroma resection and ulnar tethering release (triangular fibrocartilage complex). Patients were invited back and prospectively evaluated for postoperative range of motion, pain scores, self-reported and parent-reported Disabilities of the Arm, Shoulder, and Hand (DASH) and Pediatric Outcomes Data Collection Instrument (PODCI) scores. In addition, preoperative and final postsurgical follow-up forearm x-rays were reviewed. RESULTS: A total of 6 patients and 7 forearms were included in our study with an average age of 7.9 years at time of surgery. The average final follow-up was 7.4 years. With respect to range of motion, only passive radial deviation demonstrated improvement -20 to 14 degrees (P=0.01). Although there was not statistically significant change in radial articular angle, this study did find an improvement in carpal slip 75.7% to 53.8% (P=0.03). At final follow-up DASH score was 5.71 (σ=5.35), PODCI Global Function score was 95.2 (σ=5.81), and PODCI-Happiness score 98 (σ=2.74). Visual analogue scale appearance and visual analogue scale pain assessment were 1.67 (σ=1.21) and 1.00 (σ=1.26), respectively, at final follow-up. No patient in the cohort developed a radial head dislocation. Only one of 7 forearms required a corrective osteotomy within the study's follow-up time period. CONCLUSIONS: Surgical excision of forearm osteochondromas with ulnar tether release in the preadolescent patients improves carpal slip, may help to prevent subsequent surgical reconstruction and provides satisfactory clinical results at an average 7-year follow-up. LEVEL OF EVIDENCE: Level III-therapeutic study.

Bilateral Tubercular Dactylitis: Unusual presentation of an usual disease.

INTRODUCTION: Bilateral Tubercular Dactylitis (TD) is an unusual presentation of tuberculosis and only handful numbers of cases are reported in the literature. Hence, very little is known about its clinical presentation, statistic, radiological features and its outcome. METHODS: We have included seven male and two female patients of mean age 7.2 years, of the proven cases of bilateral TD by histopathological or microbiological or PCR analysis from core biopsy. Radiological features were recorded from plain radiograph. All patients were given Antitubercular drugs according to WHO 2010 recommendation (four drugs for 3-5 months, three drugs for next 3-5 months and finally two drugs for 6-8 months). Debridement was done whenever required. RESULTS: Of total 26 lesions, the most common presentation was swelling with or without mild pain. Discharging sinus was present in four lesions. There were six phalanges, 18 metacarpal and two metatarsals. Radiographically, the most common type of lesion was soft tissue swelling followed by lytic lesion. Histopathologically tuberculosis was proven in 10 (55.6%) lesions, bacteria isolated in 5 (27.8%) lesions and PCR was done in 8 lesions and was positive in all. All lesions healed after giving ATT except one which developed psudo-arthrosis and one patient developed coronal plane deformity that was corrected by JESS. CONCLUSION: A clinician should always suspect tuberculosis while dealing with a pathology of hand and feet even if it is bilateral. Suspected case can be diagnosed by histopathological, microbiological or PCR analysis and it can be treated by ATT with a good functional outcome.

Mallet Finger.

This article provides an overview of issues associated with traumatic injury to the distal finger that results in extensor tendon disruption or bony avulsion at the base of the distal phalanx. Commonly referred to as mallet finger, drop finger, or baseball finger, terminal extensor tendon injuries are a common presentation to the emergency department. Providers need to be advised of evidence-based management of these extensor tendon injuries in order to prevent decreased function and permanent deformity. Current evidence supports nonoperative interventions, but injuries need to be addressed in a timely manner in order to avoid poor outcomes.

A new assessment tool for ulnar drift in patients with rheumatoid arthritis using pathophysiological parameters of the metacarpophalangeal joint.

OBJECTIVES: To establish a new assessment tool for ulnar drift (UD) in rheumatoid arthritis (RA). METHODS: We established an observational cohort of 67 patients (134 rheumatoid hands) beginning in 2004. Fifty-two patients (100 hands) had follow-up in 2009 and 37 patients (63 hands) completed follow-up in 2015. UD was evaluated with the Fearnley classification and our scoring method, which assesses four parameters of the metacarpophalangeal joint. Cluster analysis using UD parameters divided hands into groups. Changes in UD over time, correlation of the Fearnley stage and cluster with a functional assessment, and reliability of the parameters were analyzed. RESULTS: UD increased and worsened over time according to the trend test. A dendrogram indicated five clusters would be appropriate. Both the Fearnley classification and cluster were associated with function; however, our method related to function more linearly (R-squared: 0.42). We found one type of hand in which bone destruction precedes the joint dislocation and one type in which joint dislocation progresses with little deviation during UD progression. CONCLUSION: Our UD evaluation appeared to be simple and related to function. Additionally, it enables dividing UD hands into five stages. Thus, our assessment should be beneficial compared to the Fearnley classification in considering treatments of UD.

An 11-year-old with mallet finger.

An 11-year-old girl presented with pain and deformity in her right little finger distal interphalangeal joint (DIPJ). She was active in several sports including hurling and had a history of dyspraxia with frequent minor soft tissue injuries which had not required hospital assessment. Her mother was concerned about the possibility of a recent injury.Examination showed flexion deformity of the right fifth finger with complete loss of extension at the DIPJ. There was mild swelling and tenderness of the DIPJ with no bruising, erythema or warmth. An X-ray was performed (figure 1). emermed;35/11/679/F1F1F1Figure 1An teroposterior (AP) and lateral radiographs of the right little finger. QUESTION: What is the diagnosis?Salter-Harris type 1 fracture of distal phalanxDystelephalangyExtensor digiti minimi tendon injuryClinodactyly.

Prevalence and characteristics associated with dactylitis in patients with early spondyloarthritis: results from the ESPeranza cohort.

OBJECTIVES: Dactylitis is a typical feature of psoriatic arthritis. However, dactylitis was included as a spondyloarthritis (SpA) feature for both (axial and peripheral) of the ASAS classification criteria, but data about its prevalence are scarce, especially in patients with a recent onset of the disease. Our objective was to determine the prevalence and characteristics associated with dactylitis in patients with early SpA. METHODS: A baseline dataset from the ESPeranza cohort was used. This programme included patients who were suspected of having SpA (age <45 years, symptoms duration of 3-24 months and with inflammatory back pain, or asymmetrical arthritis, or spinal/joint pain plus ≥1 of the SpA features). For this study, 609 patients who were diagnosed with SpA by their physician were included. Descriptive, univariable and multivariable logistic regression analyses were employed to investigate the association between the presence of dactylitis and the characteristics associated with SpA. RESULTS: Fifty-eight (9.5%) patients currently or previously had dactylitis. In the multivariable analysis, dactylitis was independently associated with peripheral arthritis (OR= 4.83; p<0.001), enthesitis (OR= 2.49; p=0.01), psoriasis (OR= 3.62; p<0.01) and the physician's visual analogue scale (OR= 0.82; p=0.01). However, 67% of the patients who had dactylitis did not have peripheral arthritis or psoriasis and 15% had predominantly axial disease. CONCLUSIONS: Dactylitis is a frequent manifestation in patients with SpA, even during the early stages of the disease. Its presence is mainly associated with peripheral manifestations and psoriasis. Nevertheless, dactylitis is not exclusive of patients with PsA or peripheral manifestations.

An algorithmic approach for the management of hand deformities in dystrophic epidermolysis bullosa.

Treatment of hand deformities in epidermolysis bullosa patients represents a challenging field in hand surgery practice, thus a systematic approach by a team is mandatory for a successful result. A simple and practical algorithm for the surgical treatment of hand deformities in EB was employed by the authors where the deformities of each digit in EB patients was categorized according to pseudosyndactyly and interphalangeal joint contracture severity for guidance during the surgical treatment. The current study retrospectively reviewed the medical records and photographic data of 13 EB patients followed in our department, for whom a systematic approach to the management and treatment was used. Mild cases were treated by surgical release and secondary healing with non-adhesive dressing while moderate cases were treated with autologous dermal grafts harvested with a special technique that were fixed on denuded areas on the proximal interphalageal joints after release. The remaining areas were treated similarly to the mild group. Additional K-wires were applied for two weeks in severe cases. A total of 21 procedures were performed on 13 EB patients with hand deformities according to the proposed treatment strategy. Functional recovery was satisfactory for each patient and the outcomes were dependent upon the severity of deformity. A multidisciplinary and conscious approach followed by an algorithmic surgical treatment protocol described in the study has been beneficial in providing consistent and successful long-term results for these patients.

Identifying barriers to the care of the rheumatoid hand in China: comparing attitudes of rheumatologists and hand surgeons.

AIM: In China, hand surgeons treat fewer rheumatoid arthritis (RA) patients compared to other countries. We investigated whether physician and surgeon knowledge, attitudes and practices regarding RA hand deformities reflect current evidence and may contribute to the low utilization of surgery. METHOD: We surveyed hand surgeons and rheumatologists at three tertiary hospitals in Beijing, China. Questionnaires were developed from literature and expert review to assess their knowledge, attitudes and practice patterns related to rheumatoid hand surgery. RESULTS: Thirty-five hand surgeons and 59 rheumatologists completed the survey. Roughly one-third felt that the rheumatologists and hand surgeons agree on how to manage RA hand deformities. One-fifth of rheumatologists and 29% of hand surgeons believed that drug therapy can correct hand deformities, which contradicts current evidence. Likewise, 30% and 14%, respectively, recommended surgery for early-stage hand sequelae that do not meet current indications for surgery. Over 80% of surgeons and rheumatologists had no exposure to the other specialty during training and felt their training on the treatment of rheumatoid hand deformities was inadequate. CONCLUSION: Although we found similar interspeciality disagreement in China as is seen in the United States, there appears to be less interaction through training and consultations. Our results also indicate potential deficits in training and unawareness of evidence and indications for rheumatoid hand surgery. These findings help to explain why surgery for rheumatoid hand deformities is rare in China; doctors have fewer opportunities to collaborate across specialties and may not be able to select appropriate candidates for surgery.

Mallet Finger in a Toddler: A Rare But Easily Missed Injury.

A mallet finger is a flexion deformity of a finger at the distal interphalangeal joint due to an injury of the extensor mechanism at the base of the distal phalanx. Most common in middle-aged men, injuries in the pediatric population are less common and rare in toddlers. We describe a case of missed mallet finger and its subsequent treatment in a female toddler.

Acute Traumatic Swan Neck Deformity: A Case Report of the Oblique Retinacular Ligament Lesion.

Swan neck deformity (SND) can be the manifestation of an acute trauma. We present a case report of a young basketball player with an acute traumatic SND determined by the single ulnar oblique retinacular ligament rupture. The patient caught a ball directly upon the tip of his right's hand middle finger into extension. He immediately presented a SND with impossibility to actively flex the proximal interphalangeal joint (PIPJ), while preserving active flexion and extension of the distal interphalangeal joint (DIPJ). Hyperextension of PIPJ was reducible with passive mobilization, thus allowing full passive range of motion. The SND was seen to be caused by the lesion of the ulnar oblique retinacular ligament (ORL) on its distal insertion, with consequent dorsomedial migration of the ulnar lateral band. The early surgical distal reinsertion of the ORL allowed the restoration of the original kinematics of the finger flexion-extension.

Paquidermodactilia, engrosamiento digital proximal. Pachydermodactyly, digital proximal thickening.

We report a case of pachydermodactyly (PDD). PDD is a benign, asymptomatic soft tissue swelling affecting the skin of the lateral aspects of the proximal interphalangeal joints of the fingers, mostly in young adolescent males. It has often been interpreted as a consequence of tic-like behavior as part of an obsessive-compulsive disorder. Although the diagnosis is essentially clinical, skin biopsy shows compact orthokeratotic hyperkeratosis, increased numbers of collagen fibers and fibroblasts, and no inflammatory changes. A rapid clinical recognition of PDD should avoid many unproductive and expensive diagnostic tests.

The influence of Dupuytren's disease fingers contracture degree on surgical treatment outcome.

Background/Aim: Dupuytren's disease is a progressive disease of the palmar and digital fascial structures, with functional limitations. There are no clear recommendations about the optimal time of surgical repair, concerning the hand impairment. The aim of our study was to investigate the relation between finger's contracture degree and success of surgical treatment of the Dupuytren's disease. Methods: This prospective analysis included 60 patients operated on due to Dupuytren's contracture. According to preoperative contracture degree of proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joint, patients were divided into three groups: the group 1: < 15°, the group 2: 15−30° and the group 3: > 30°. All the patients underwent operation of partial palmar fasciectomy. Postoperative improvement was expressed with contracture reduction INDEX. Results: There were 60 patients with 85 fingers affected. The groups 1, 2 and 3 had 22 (37%), 37 (62%) and 26 (43%) fingers with MCP contracture and 32 (37.4%), 24 (28.2%) and 29 (34.1%) fingers with PIP contracture, respectively. Postoperative contractures of MCP joint in these groups were 0, 0.135° and 5°, and of PIP joint 0, 2.08 ° and 16.89°, respectively. After six months all MCP contractures resolved, while PIP joint contracture in the group 3 remained 13.62°. The reduction INDEX was 98.85%, 97.62% and 75.52% in the groups 1, 2 and 3, respectively. There was a statistically significant difference in the INDEX value between the groups (p = 0.0001). Conclusion: The degree of PIP joint contracture is related to the outcome of surgical treatment of Dupuytren's disease. Optimal results are achieved when contracture degree is between 15° and 30°. Surgical treatment of MCP joint contracture is successful regardless of the preoperative joint contracture degree.

Relative motion orthoses in the management of various hand conditions: A scoping review.

STUDY DESIGN: Scoping review. INTRODUCTION: The relative motion (RM) concept and immediate controlled active motion (ICAM) program, originally applied after zones IV-VII extensor tendon repairs, have been modified and extended to a variety of hand conditions, such as sagittal band injury, boutonniere deformity, and extensor lag. PURPOSE OF THE STUDY: To scope the published and unpublished literature to review ICAM modifications, hand conditions for which the RM concept is used, and describe the preferred degree of relative metacarpophalangeal joint extension/flexion reported and spectrum of orthosis design. METHODS: Electronic and manual searches of scientific and gray literature and expert consultation were conducted. Documents with quantitative data were assessed with Oxford Levels of Evidence and the Structured Effectiveness Quality Evaluation Scale. RESULTS: Fifteen references met the inclusion criteria; 1 was level III evidence, and others were level IV evidence. RM-ICAM modifications, preferred degree of relative extension/flexion, orthotic design, management of other hand conditions and knowledge gaps were identified. CONCLUSION: RM orthoses may improve outcomes in a variety of hand conditions; however, high-quality studies that contribute to the evidence base for its use are needed. LEVEL OF EVIDENCE: Not applicable.