Increase of weight-bearing capacity of patients with lesions of the TFCC using a wrist brace.

STUDY DESIGN: Retrospective cross-sectional case series. BACKGROUND: Lesions of the triangular fibrocartilage complex (TFCC) can result in pain during axial load and unstable distal radioulnar joint (DRUJ). Conventional wrist orthoses decrease initial pain sufficiently but also prevent any movement during recovery and do not contribute to the stabilization of the DRUJ. PURPOSE: In this retrospective analysis, we tested if the weight-bearing capacity of patients with lesions of the triangular fibrocartilage complex was increased by wearing a brace that stabilizes the distal radioulnar joint. METHODS: Twenty-three patients had an arthroscopically confirmed TFCC lesion. We compared preoperative dynamic weight-bearing capacity of both hands with and without a commercially available wrist brace (WristWidget). Subgroup analysis was performed for stability of the distal radioulnar joint and etiology of the TFCC lesion. The dynamic ulnar variance was measured in a modified weight bearing test. We used parametric tests for normally distributed values. RESULTS: The weight-bearing capacity of the hand with TFCC lesion was significantly lower than of the control hand (16 verus 36 kg; p <0.001). The relative load of the affected hand compared to the unaffected hand increased from 48 % (CI 37-60, SD 27) to 59 % (CI 47-72, SD 29) with a brace. The device had no effect on the control hand. Twelve patients with unstable DRUJ had a lower weight-bearing capacity compared to the eleven with stable joint. The percentage improvement with bracing was higher for those with unstable joints (versus stable) and traumatic lesions (versus degenrative). CONCLUSION: The use of a wrist brace significantly increases the weight-bearing capacity and therefore the maximum tolerated axial load of patients with a lesion of the TFCC. Patients with traumatic lesion or unstable DRUJ tend to show lower values than with degenerative lesions or stable joints.

Incidence and underreporting of osseous wrist and hand injuries on whole-body computed tomographies at a level 1 trauma center.

BACKGROUND: To investigate the incidence of osseous wrist and hand injuries on whole-body computed tomographies (WBCT) at an urban maximum-care trauma center, to report the number of missed cases in primary radiology reports, and to develop an algorithm for improved detection of these injuries. METHODS: Retrospective analysis reviewing all WBCT for a period of 8 months for osseous wrist and hand injuries. (1) Reconstruction of hands/wrists in three planes (thickness 1-2 mm) and analysis by a blinded musculoskeletal radiologist. (2) Scanning of primary radiology reports and comparison to the re-evaluation. (3) Calculation of the diagnostic accuracy of WBCT during primary reporting. (4) Search for factors potentially influencing the incidence (trauma mechanism, associated injuries, Glasgow Coma Scale, artifacts). (5) Development of an algorithm to improve the detection rate. RESULTS: Five hundred six WBCT were included between 01/2020 and 08/2020. 59 (11.7%) WBCT showed 92 osseous wrist or hand injuries. Distal intra-articular radius fractures occurred most frequently (n = 24, 26.1%); 22 patients (37.3%) showed multiple injuries. The sensitivity of WBCT in the detection of wrist and hand fractures during primary evaluation was low with 4 positive cases identified correctly (6.8%; 95% CI 1.9 to 16.5), while the specificity was 100% (95% CI 99.2 to 100.0). Forty-three cases (72.9%) were detected on additional imaging after clinical reassessment. Twelve injuries remained undetected (20.3%). Motorcycle accidents were more common in positive cases (22.0% vs. 10.1%, p = 0.006). 98% of positive cases showed additional fractures of the upper and/or lower extremities, whereas 37% of the patients without osseous wrist and hand injuries suffered such fractures (p < 0.001). The remaining investigated factors did not seem to influence the occurrence. CONCLUSION: Osseous wrist and hand injuries are present in 11.7% on WBCT after polytrauma. 93.2% of injuries were missed primarily, resulting in a very low sensitivity of WBCT during primary reporting. Motorcycle accidents might predispose for these injuries, and they often cause additional fractures of the extremities. Clinical re-evaluation of patients and secondary re-evaluation of WBCT with preparation of dedicated multiplanar reformations are essential in polytrauma cases to detect osseous injuries of wrist and hand reliably. TRIAL REGISTRATION: The study was registered prospectively on November 17th, 2020, at the German register for clinical trials (DRKS-ID: DRKS00023589 ).

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment.

BACKGROUND: We examined the visibility of fractures of hand and forearm in whole-body CT and its influence on delayed diagnosis. This study is based on a prior study on delayed diagnosis of fractures of hand and forearm in patients with suspected polytrauma. METHODS: Two blinded radiologists examined CT-scans of patients with fractures of hand or forearm that were diagnosed later than 24 h after admission and control cases with unremarkable imaging of those areas. They were provided with clinical information that was documented in the admission report and were asked to examine forearm and hands. After unblinding, the visibility of fractures was determined. We examined if time of admission or slice thickness was a factor for late or missed diagnoses. RESULTS: We included 72 known fractures in 36 cases. Of those 65 were visible. Sixteen visible fractures were diagnosed late during hospital stay. Eight more fractures were detected on revision by the radiologists. Both radiologists missed known fractures and found new fractures that were not reported by the other. Missed and late diagnoses of fractures occurred more often around 5 pm and 1 am. Slice thickness was not significantly different between fractures and cases with fractures found within 24 h and those found later. CONCLUSIONS: The number of late diagnosis or completely missed fractures of the hand and forearm may be reduced by a repeated survey of WBCT with focus on the extremities in patients with suspected polytrauma who are not conscious. LEVEL OF EVIDENCE: III.

Results of a special interdisciplinary hand therapy program for work-related injuries.

The importance of postoperative care of hand injuries is undisputed, but sometimes more intensive therapy is needed. The objective of this study was to evaluate the benefits of a specialized hand rehabilitation program supervised by hand surgeons. The outcomes and short-term follow-up of 76 patients with upper extremity injuries were analyzed through patient self-reported parameters as well as objective functional scores. Improvement in all self-assessed parameters during rehabilitation was statistically significant for the DASH (p<0.001) as well as the EQ-5D (p<0.05). Further improvement in the short-term (14 weeks) was only seen for the DASH score (p<0.05). During rehabilitation, there was a statistically significant improvement in all objective measurements. Among patients with finger injuries, 71% were able to return to work. Our specialized hand rehabilitation program provides benefits for all patients. There are differences between types of upper extremity injuries in terms of the effects and necessary treatments.

[Recurrence of septic arthritis of the wrist by Pseudomonas aeruginosa due to colonization of a central venous indwelling catheter]. / Rezidiv einer septischen Arthritis des Handgelenks durch Pseudomonas aeruginosa bei Besiedelung eines zentralvenösen Verweilkatheters.

A diabetic patient, wearer of a port and with a history of gonarthritis due to Pseudomonas aeruginosa presented with subacute arthritis of a wrist. After a protracted interval P. aeruginosa was detected by microbial culture from the explanted port and the affected joint. This case shows that in patients with unclear arthritis of the wrist, a history of septic arthritis with P. aeruginosa and risk factors for hematogenous spread, a recurrent infection should be excluded. The treatment consisted of explantation of the port, débridement with synovectomy of the joint and adequate antibiotic treatment.

[Pedicled vascularized iliac bone graft for treatment of osteonecrosis of the femoral head]. / Gefäßgestieltes Beckenkammtransplantat zur Behandlung der Femurkopfnekrose.

OBJECTIVE: Illustration of a nowadays only rarely performed operative procedure for the treatment of osteonecrosis of the femoral head to prevent or at least delay advanced arthrosis and the need for a total hip replacement. The pedicled vascularized iliac bone graft is raised without the need for special microsurgical techniques and has less vascular complications often seen in free vascularized grafts. INDICATIONS: Early stages of osteonecrosis of the femoral head stages II and III according to the Association Research Circulation Osseous (ARCO) up to the detection of fracture lines (crescent sign) but without mechanical insufficiency. CONTRAINDICATIONS: Osteonecrosis of the femoral head with collapse of the femoral head (ARCO stage ≥IIIB) and mechanical insufficiency. Patients who are noncompliant or a not able to take the weight off the operated leg. Patients who had radiotherapy or an operation on ipsilateral inguinal lymph nodes and patients who have vascular anomalies or severe arteriosclerosis. SURGICAL TECHNIQUE: Debridement of the femoral head osteonecrosis and implantation of a pedicled vascularized iliac bone graft. POSTOPERATIVE MANAGEMENT: Free movement of the hip joint 4 weeks after surgery. Outward rotation of the hip joint allowed after 3 months and restriction of weight load on the operated leg for at least 3-6 months postoperatively depending on the bony consolidation. RESULTS: Vascularized bone grafts for the treatment of femoral head necrosis show better clinical and radiological results than avascular bone grafts. Nevertheless, after 5 years follow-up approximately 25% of the operated hips formerly in stage II show further progression of radiological necrosis. In stage III all hips eventually show progress of femoral head collapse and the need of a total hip replacement. Concerning the outcome of a free vascularized bone graft (fibula flap) compared to the pedicled vascularized graft from the iliac crest for treatment, the anatomically demanding area and a higher complication rate should be considered even though the cancellous bone of the iliac crest is biologically ideal. Nowadays a free vascularized fibular graft is the most frequently used bone graft for treatment of femoral head necrosis.

Detection of fractures of hand and forearm in whole-body CT for suspected polytrauma in intubated patients.

BACKGROUND: The aim of this study was to evaluate the potential of whole-body CT for diagnosis of hand and forearm fractures in intubated patients with suspected polytrauma. METHODS: We performed a retrospective analysis on data collected from two trauma centres in Germany, including demographics, ISS, clinical symptoms, depiction in whole-body CT, and time to diagnosis. RESULTS: Out of 426 patients included in the study, 66 (15.5%) suffered a hand or forearm fracture. The total number of fractures was 132, the whole-body CT report mentioned 98 (74.2%). 16 (12,1%) fractures of 12 patients were diagnosed later than 24 h after admission. Late diagnoses of fractures of the hand occurred more often if the hand was not fully included in the CT scan field. The sensitivity of whole-body CT for cases with fractures of hand and/or forearm with full inclusion of the corresponding area in the scan field was 80.2%. CONCLUSIONS: This study shows that whole-body CT is a valuable diagnostic tool for hand fractures in polytrauma patients. Hands should be evaluated regardless of clinical presentation in intubated patients after suspected polytrauma if they are included in the whole-body CT.

Proximal interphalangeal joint arthrodesis using a compression wire: A comparative biomechanical study.

Arthrodesis of the proximal interphalangeal joint is a proven technique for treating of a range of pathological conditions, including osteoarthritis. There are multiple surgical procedures. A biomechanical study was conducted to compare the stability of a compression wire to intraosseous wiring for the arthrodesis. Seventeen formalin-fixed human fingers were randomly assigned into two groups and the bone mineral density was determined. Arthrodesis in 20° flexion was performed using an oblique compression wire (n=8) or intraosseous wiring (n=9). The stability of the arthrodesis was tested by applying a tensile bending force until failure. The mean force needed to fail the compression wire arthrodesis and intraosseous wire arthrodesis was not significantly different (76.2N, SD 31N and 63.0N, SD 28N). There was no correlation between bone density and force to failure. The compression wire was within the approximate range achieved by intraosseous wiring in withstanding substantial force before failure. From a biomechanical point of view, a compression wire is feasible for PIP arthrodesis.

Superselective angiography of the wrist in patients with Kienböck's disease.

BACKGROUND: Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck's disease. We examined if wrist position modifies the blood flow in the nutrient vessels. METHODS: Retrospective analysis of 17 patients with Kienböck's disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher's exact and Wilcoxon-test. RESULTS: We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position. CONCLUSION: The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

[Traumatic lesions of the brachial plexus : Clinical symptoms, diagnostics and treatment]. / Traumatische Läsionen des Plexus brachialis : Klinische Symptome, Diagnostik und Therapie.

Brachial plexus lesions mostly occur in young patients as a result of high-speed accidents. They are often diagnosed and treated after a delay. This has been shown to worsen the prognosis of surgical reconstructions evidently. In 70-80% of traumatic lesions functional reinnervation can be achieved by various surgical procedures. An early sufficient diagnosis and the subsequent referral of the patient to an appropriate competence center for consultation and, if necessary, surgery are therefore essential.

[The scaphoid and rheumatoid arthritis : Classification by retrospective X­ray analysis]. / Das Skaphoid bei Rheuma : Klassifikation anhand einer retrospektiven Röntgenanalyse.

BACKGROUND: Early destruction of the wrist in rheumatoid arthritis is common and often progressive. Even in times of improved and standardized medical treatment this cannot always be prevented. OBJECTIVES: A limited range of motion, pain, reduced grip-force, and aesthetic deficits of the wrist can impair the daily life of patients. There is an additional risk for destruction of the surrounding soft tissue and adjoining joints of the upper extremity. RESULTS: Destruction of wrist in rheumatoid arthritis is multifactorial and is localized in many different structures of the wrist. In this context, scaphoid and periscaphoid structures are of interest. Data were gathered in a retrospective study of the wrist X­rays of patients with rheumatoid arthritis. The possible consequences for operative options are described.

[Pedicled vascularized bone graft for scaphoid reconstruction after Zaidemberg]. / Das gestielte vaskularisierte Knochentransplantat zur Skaphoidrekonstruktion nach Zaidemberg.

BACKGROUND: Nonunion of the scaphoid as a result of proximal fractures, failed surgical reconstruction, and especially avascular fragment necrosis are possible indications of vascularized bone grafts. Various techniques of vascularized (pedicled and free) grafts have been described. Pedicled grafts from the direct vicinity of the wrist provide several benefits. Harvest-site morbidity is reduced and preserved graft perfusion, without the need for blood vessel anastomosis, may lead to an improved consolidation. METHODS: A common pedicled vascularized bone graft for reconstruction of the scaphoid was first described by C. Zaidemberg and colleagues in 1991. We describe 49 consecutive patients, who underwent vascularized bone-grafting, pedicled on the 1.2 intercompartmental, supraretinacular artery in a modified technique based on Zaidemberg's description. The fixation of the bone graft was performed by Kirschner wires. RESULTS: A consolidation was detected in 37 cases, and 9 cases showed a persistent nonunion (3 patients did not follow up). According to the classification of Herbert, 44 patients had a nonunion grade D2 or higher, of which 36 patients showed a bony consolidation (8 non-consolidated). Complications occurred in individual cases (1x intraoperative fracture of the radius, 4x transient irritations of the superficial branch of the radial nerve). A loss in the range of motion of the affected wrist was frequent. An indication for a pedicled graft was seen if the preoperative contrast-enhanced MRI showed an impaired perfusion of scaphoid fragments. DISCUSSION: The more advanced the changes in MRI, the more frequently treatment failed. The vascularized bone graft from the dorsal distal radius described by C. Zaidemberg et al. is one of several ways to address a circulation-impaired nonunion of the scaphoid.

[Scaphoid pseudarthrosis : Indications for avascular iliac crest or radius bone grafts]. / Skaphoidpseudarthrose : Indikationsbereiche für das avaskuläre Beckenkamm- oder Radiustransplantat.

BACKGROUND: Operative treatment of the scaphoid nonunion includes avascular corticocancellous and cancellous bone grafts and increasingly the use of vascular pedicled and free vascular corticocancellous grafts. Especially the latter require a fair amount of operative expertise and experience in microsurgical techniques. OBJECTIVE: Which criteria lead to the decision for or against an avascular graft used for reconstruction of scaphoid nonunion? Is our current classification system of a scaphoid pseudarthrosis able to illustrate our diagnostic potential in a way that makes us refer to operative procedures? METHODS: Evaluation of current literature and expert opinions RESULTS: Avascular bone grafts show a high union rate as long as a sufficient vascularisation of the remaining fragments is present. In general, patients benefit from a very good functional outcome. Even revisions of failed scaphoid union may be successfully treated with an avascular bone graft. Failures of union are repeatedly experienced in treating proximal pole fractures with critical vascularisation or extensive bone loss, especially including avascular necrosis of the proximal pole (AVN). Current classification systems do not allow description and correlation of morphologic findings so as to compare results profoundly and to recommend specific procedures. CONCLUSIONS: As long as sufficient vascularisation of remaining fragments is seen, the avascular bone graft is eligible for reconstructing scaphoid nonunion. Classification systems do not seem to reflect the status quo of diagnostic possibilities and make it difficult to provide guidelines for state-of-the-art operative procedures.

[Diagnosis of the scaphoid bone : Fractures, nonunion, circulation, perfusion]. / Diagnostik des Skaphoids : Fraktur, Pseudarthrose, Durchblutung, Perfusion.

The clinical relevance of scaphoid bone fractures is reflected by their high incidence, accounting for approximately 60 % among carpal fractures and for 2-3 % of all fractures. With adequate therapy most scaphoid bone fractures heal completely without complications. Insufficient immobilization or undiagnosed fractures increase the risk of nonunion and the development of pseudarthrosis.X-ray examination enables initial diagnosis of scaphoid fracture in 70-80 % of cases. Positive clinical symptoms by negative x­ray results require further diagnostics by multi-slice spiral CT (MSCT) or MRI to exclude or confirm a fracture. In addition to the diagnosis and description of fractures MSCT is helpful for determining the stage of nonunion. Contrast enhanced MRI is the best method to assess the vitality of scaphoid fragments.

[Rehabilitation after flexor tendon injuries of the hand]. / Rehabilitation nach Beugesehnenverletzungen an der Hand.

BACKGROUND: Advances in basic research evaluating suture material, techniques, and maximum tendon load with regard to repair site failure help to decide between rehabilitation protocols after the repair of flexor tendon injuries. OBJECTIVES: The presentation and choice of rehabilitation protocols depending on the mechanism of injury and knowledge of the influencing factors concerning tendon load. Expected outcome after flexor tendon repair. METHODS: Evaluating recent literature and basic research investigations, and presenting expert opinions. RESULTS: Based on the mechanism of injury, the suture technique, the compliance of the patient, and the latest knowledge on tendon capacity help to choose from the basic principles of rehabilitation protocols: passive or early motion protocols, such as those described by Duran-Houser and Kleinert, in the majority of cases lead to good and fair results according to the Hand Functional Score of the American Society for Surgery of the Hand. A larger number of excellent functional results are seen after the rehabilitation of flexor tendon injuries using combined passive/active or completely active motion protocols, e.g., according to Small. In addition to choosing a specific protocol and considering different zones of injury, it is essential to thoroughly supervise therapy and to monitor the adjustment of splints. It is widely recommended that patients should be provided with additional scar treatment and physical therapy throughout their entire rehabilitation. CONCLUSIONS: Flexor tendon injuries, especially in zone 2, are still a challenge with regard to operative treatment and rehabilitation, with an unpredictable outcome. Further knowledge and advances in suture techniques and material will support the use of active motion protocols and improve functional results in the future.

Cine MRI: a new approach to the diagnosis of scapholunate dissociation.

OBJECTIVE: To evaluate the feasibility of cine MRI for the detection of scapholunate dissociation (SLD) and to compare the sensitivity and specificity of cine MRI with those of cineradiography and arthroscopy. MATERIALS AND METHODS: To evaluate feasibility, healthy subjects underwent cine MRI of the wrist. To evaluate sensitivity and specificity, patients with clinically suspected scapholunate ligament (SLL) injury after trauma to the wrist were prospectively included and underwent radiographic examination, cineradiography, and cine MRI. In 25 out of 38 patients, subsequent arthroscopy was performed. Results of cineradiography and cine MRI correlated with those of arthroscopy. RESULTS: Cine MRI was of diagnostic quality in all healthy subjects and patients with good interrater agreement. There was excellent correlation between cineradiography and cine MRI. Scapholunate distance differed significantly between healthy subjects and patients with scapholunate dissociation (p < 0.001), but not between imaging modalities in the patient group. Cine MRI had 85% sensitivity and 90% specificity for the detection of SLD. CONCLUSION: Cine MRI of the wrist is a fast and reliable technique for the detection of SLD with diagnostic accuracy comparable to cineradiography. It can be easily implemented as a routine clinical MRI examination, facilitating diagnostic workup of patients with suspected SLD while avoiding radiation exposure.

[Operative options for rectification after failed osteosynthesis of the distal radius]. / Operative Rückzugsmöglichkeiten nach fehlgeschlagener Osteosynthese des distalen Radius.

BACKGROUND: Even in an era of clear improvements in implants and standardized treatment procedures, abortive osteosynthesis after distal radius fractures is not an uncommon complication. DIAGNOSTICS: Although not every malunion of the radius leads to complaints, affected patients often suffer from limitations in movement, reduction in strength, pain and aesthetic deficits. Following thorough clinical and imaging diagnostics a selection from the possible treatment options must be made taking the results obtained from the diagnostics into consideration. THERAPY: Operative possibilities are available for reconstructing the anatomical features as accurately as possible, functional improvement without correction of the malunion, pain reduction alone and combined procedures. CONCLUSION: Despite abortive osteosynthesis of distal radial fractures there are possibilities for anatomical reconstruction, retention of mobility and pain reduction. Taking the pathological deformities into consideration, the highest priority should be given to reconstructing the anatomical joint conditions as accurately as possible, even when the conservative treatment options were unsuccessful.