Acute fingertip and nail injuries in the hand.

A correct diagnosis and treatment of fingertip- and nail injuries, commonly seen in the emergency room, is crucial. Insufficient treatment can result in long-term complications, including finger dysfunction and dysaesthesia, nail deformity, infection, or pain. These remaining problems may induce severe impairment of the quality of life of the patient. This review summarises the diagnosis and treatment.

Effects of a neuromuscular joint-protective exercise therapy program for treatment of wrist osteoarthritis: a randomized controlled trial.

BACKGROUND: Individuals with wrist osteoarthritis (OA) can suffer from pain, muscular weakness, and impaired motion of the wrist, which can reduce the quality of life. While there is strong evidence that all patients with OA should receive first-line treatment with education and exercises, this approach has not yet been proposed for individuals with wrist OA. Therefore, this trial aimed to evaluate the effectiveness of a first line neuromuscular joint-protective exercise therapy program compared to a training program with range of motion (ROM) exercises in patients with wrist OA. METHODS: In this randomized controlled trial (RCT), 48 patients with symptomatic and radiographically confirmed wrist OA were randomly allocated to a 12-week self-management program with either a neuromuscular joint-protective exercise therapy program (intervention group) or a training program with ROM exercises only (control group). Our primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) with secondary outcome measures of grip strength, range of wrist motion, the Numerical Pain Rating, Scale (NPRS), the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Generalized Self-Efficacy Scale (GSES). The outcome measures were evaluated by a blinded assessor at baseline and 12 weeks. Between-groups differences were analyzed using the Mann-Whitney U test and within-group differences were analyzed with the Wilcoxon signed-rank test. RESULTS: A total of 41 participants were analyzed at 12 weeks. There were no significant differences in PRWE between the groups at 12 weeks (p = 0.27). However, DASH improved significantly in the intervention group compared to the control group (p = 0.02) and NPRS on load within the intervention group (p = 0.006). The difference in DASH should be interpreted with caution since it could be due to a non-significant increase (worsening) from baseline in the control group in combination with a non-significant decrease (improvement) in the intervention group. CONCLUSIONS: This RCT showed that the novel neuromuscular joint-protective exercise therapy program was not superior in reducing pain and improving function compared to a training program with ROM exercises at 12 weeks. Future research is warranted to evaluate the effectiveness of forthcoming exercise therapy treatment programs for patients with wrist OA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05367817. Retrospectively registered on 10/05/2022. https://clinicaltrials.gov .

Clinical and Patient-Reported Outcomes After Total Wrist Arthroplasty and Total Wrist Fusion: A Prospective Cohort Study with 2-Year Follow-up.

Background: The functional benefits of total wrist arthroplasty (TWA) over total wrist fusion (TWF) are unknown. The purpose of this prospective cohort study was to compare TWA and TWF with respect to functional outcomes and activity limitations at up to 2 years postoperatively. Methods: Between 2015 and 2020, we enrolled all adult patients undergoing TWA or TWF for the management of symptomatic end-stage wrist arthritis at 1 hand surgery department. The primary outcome was the Patient-Rated Wrist Evaluation (PRWE). The secondary outcomes were the visual analog scale (VAS) for pain at rest, on motion, and on loading; grip strength; Disabilities of the Arm, Shoulder and Hand (DASH); and range of motion. Patients completed questionnaires and were examined by the same physiotherapist at baseline and at 3, 6, 12, and 24 months postoperatively. Mixed-model analyses adjusting for age, diagnosis, the preoperative value of the dependent variable, and time since surgery were performed to compare differences in PRWE scores, VAS pain scores, and grip strength between TWA and TWF. Results: Of the 51 patients who had been included at baseline, 47 (18 in the TWA group and 29 in the TWF group) responded to questionnaires and underwent examinations at up to 2 years postoperatively. At baseline, the 2 groups did not differ in terms of age, sex, diagnosis (inflammatory or noninflammatory arthritis), PRWE score, VAS pain score, grip strength, DASH score, or range of motion. No differences between the groups were found for the PRWE (ß, -0.1; 95% confidence interval [CI], -14 to 13; p = 0.99), VAS pain at rest (ß, -3.3; 95% CI, -15 to 9; p = 0.58), VAS pain on loading (ß, -5.3; 95% CI, -22 to 11; p = 0.52), or grip strength (ß, -0.02; 95% CI, -0.18 to 0.14; p = 0.80) on the adjusted mixed-model analyses. Conclusions: Among patients with symptomatic end-stage wrist arthritis, those who underwent TWA did not demonstrate short-term outcomes, including patient-reported disability, pain, and grip strength, superior to those of patients who underwent TWF. These findings call into question the widespread use of TWA. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

A self-managed exercise therapy program for wrist osteoarthritis: study protocol for a randomized controlled trial.

BACKGROUND: Post-traumatic wrist osteoarthritis (OA) can eventually lead to pain, muscular weakness, and stiffness of the wrist, which can affect the function of the entire upper limb and reduce the quality of life. Although there is strong evidence that all patients with OA should be offered adequate education and exercises as a first-line treatment, an effective self-management program, including structured education and therapeutic exercises, has not yet been introduced for individuals with wrist OA. This trial aims to evaluate the effectiveness of an exercise therapy program with joint protective strategies to improve neuromuscular control (intervention group) compared to a training program with range of motion exercises (control group). METHODS: This is a single-blinded randomized controlled trial (RCT) with two treatment arms in patients with symptomatic and radiographically confirmed wrist OA. The trial will be conducted at a hand surgery department. The participants will be randomly assigned either to a neuromuscular exercise therapy program or to a training program with range of motion exercises only. Participants in both groups will receive a wrist orthosis and structured education on wrist anatomy, pathophysiology, and joint protective self-management strategies. The programs consist of home exercises that will be performed twice a day for 12 weeks. The Patient-Rated Wrist Evaluation (PRWE) is the primary outcome measure of pain and function. Wrist range of motion (ROM), grip strength, the Numeric Pain Rating scale (NPRS), Disabilities of the Arm, Shoulder, and Hand (DASH), the General Self-Efficacy Scale (GSES), Global Rating of Change (GROC), and conversion to surgery are the secondary measures of outcome. Assessments will be performed at baseline and at 3, 6, and 12 months after baseline by a blinded assessor. DISCUSSION: The upcoming results from this trial may add new knowledge about the effectiveness of a self-managed exercise therapy program on pain and function for individuals with wrist OA. If the present self-management program proves to be effective, it can redefine current treatment strategies and may be implemented in wrist OA treatment protocols. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05367817. Retrospectively registered on 27 April 2022. https://clinicaltrials.gov .

Bone Remodeling after Ulna Head Replacement in Distal Radioulnar Joint Arthroplasty: A Radiographic Comparison between a Partial and a Total Ulna Head Concept.

Background Ulna head arthroplasty has become an eligible solution for injury or disease in the distal radioulnar joint. Bone resorption beneath the prosthetic head is often reported, but mechanism poorly understood. Purpose The aims were to evaluate bone remodeling and radiological instability in two conceptually different distal radioulnar joint arthroplasties: the total and the partial ulna head replacement. Patients and Methods We conducted a retrospective radiographic assessment of 51 ulna head arthroplasties; 26 Herbert ulna (total ulna head replacement) and 25 First Choice (partial ulna head replacement), to analyze periprosthetic bone resorption and radiologic instability. Intraoperative/immediate postoperative and 1-year radiographs were reviewed by two independent assessors. The radiographic follow-up averaged 13 (10-17) months. The size of the stem in relation to the diameter of the ulna (filling ratio) was measured on the intraoperative/immediate postoperative radiographs. Bone resorption beneath the collar of the prothesis was measured on the 1-year radiographs and expressed as a bone resorption index (BRI) between the length of the resorption and the length of the implant stem. Radiological stability was measured on both the preoperative and the 1-year lateral radiographs. Results The total ulna head prothesis presented with more extensive bone resorption beneath the prosthetic head than the partial ulna head prothesis at 1-year post surgery ( p <0.001). The filling ratio did not influence the 1-year bone resorption and there was no difference regarding radiological instability between the two prosthetic designs. Conclusion The pattern of bone adaptions after an ulna head prothesis may differ due to design and concept of the prosthesis.

Striatal Hand Deformities in Parkinson's Disease: Hand Surgical Perspectives.

Background: The knowledge about striatal hand deformities (SHD) in Parkinson's disease (PD), has recently increased but need more attention due to their early impact on dexterity. The focus of clinical studies has been on the staging of SHD severity and neurological features. However, a hand surgical perspective has not been considered. Objectives: Our purpose was to examine SHD in patients with PD using hand surgical assessment methods and the recommended staging of SHD. Methods: In this observational study, a specialist in neurological physiotherapy examined 100 consecutive PD patients and identified 35 with suspected SHD, who were then examined by two hand surgeons. Their hands were clinically evaluated for severity of SHD, according to a previous proposed staging, focusing on metacarpophalangeal (MCP) joint flexion, presence of intrinsic and extrinsic tightness, as well as other hand deformities. Results: Three kinds of deformities were identified among 35 included patients: surgical diagnoses unrelated to PD (n = 5), SHD (n = 23), and PD related hand deformities with increased extrinsic tightness (n = 10); three of these 10 patients had also contralateral SHD, thus are included in SHD group. In addition to previously described MCP joint flexion, swan neck deformity and z-thumb deformity, we found in most hands finger "clefting," abduction of the little finger and/or an increased intrinsic tightness, indicating pathology of intrinsic muscles of the hand involved in SHD. Conclusions: SHD diagnosed with a modified staging method, including features of intrinsic and extrinsic hand deformities, should be considered in PD to implement early and more accurate treatment.

Psychometric properties of patient-reported outcome measures (PROMs) in wrist osteoarthritis: test-retest reliability and construct validity.

BACKGROUND: Patient-reported outcome measures (PROMs) are frequently used to assess the effects of treatments in patients with wrist osteoarthritis (OA), but their psychometric properties have not been evaluated in this group of patients. Our aim was to evaluate the psychometric properties of the Numeric Rating Scale (NRS pain at rest, pain on motion without load, and pain on load), the Disabilities of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) questionnaires in patients with wrist OA regarding test-retest reliability and construct validity. METHODS: The NRS, DASH and PRWE were self-administered by 50 patients (40 men and 10 women, mean age 66 years) in a postal survey on two occasions, two weeks apart. Test-retest reliability was evaluated by Kappa statistics and the Spearman rank correlation coefficients (rho) were calculated to evaluate construct validity. RESULTS: The Kappa coefficients for DASH, PRWE and NRS pain on motion without load and NRS pain on load were > 0.90, 95% CI ranging from 0.84 to 0.98, while NRS pain at rest was 0.83, 95% CI 0.73-0.92. The construct validity of the PROMs was confirmed by three formulated hypotheses: a higher correlation between PRWE and NRS (rho 0.80-0.91, p < 0.001) was found, compared to DASH and NRS (rho 0.68-0.80, p < 0.001); the NRS pain on motion without load and NRS pain on load correlated more strongly to PRWE and DASH (rho 0.71-0.91, p < 0.001) compared to NRS pain at rest (rho 0.68-0.80) and a high correlation between PRWE and DASH was found (rho 0.86, p < 0.001). CONCLUSIONS: The NRS, DASH and PRWE demonstrate excellent test-retest reliability and moderate to high construct validity in patients with wrist OA. These PROMs are highly related, but they also differ. Therefore, they complement each other in ensuring a comprehensive evaluation of perceived disability in wrist OA. As PRWE showed the highest test-retest reliability and the highest relation to the other PROMs, the sole use of the PRWE can be recommended in clinical practice.

Cold sensitivity, functional disability and predicting factors after a repaired digital nerve injury.

To investigate self-reported cold sensitivity and functional disability after a repaired digital nerve injury. We identified 3204 individuals operated with digital nerve repair in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity and perceived disability, were examined using two questionnaires (HQ-8 and QuickDASH), three and 12 months postoperatively. Patients with diabetes (n = 48; 3%) were identified in the Swedish National Diabetes Register (NDR). Cold sensitivity (scored 0-100) was the most prominent symptom among 1553 included individuals (998 men, 555 women; median age 41 [IQR 27-54] years). In the regression analysis, flexor tendon injury, hand fracture and injury to multiple structures predicted worsened cold sensitivity (6.9, 15.5 and 25.0 points; p = 0.005, 0.046 and < 0.001) at 12 months. Individuals with moderate (30-70) and severe (> 70) cold sensitivity had higher QuickDASH scores at three and 12 months postoperatively than individuals with mild cold sensitivity (6.0 and 5.5; 19.8 and 21.0 points; p = 0.001). Flexor tendon injury, injuries to multiple structures and diabetes had significant effect on QuickDASH scores at three, but not at 12, months postoperatively. Cold sensitivity is common after a digital nerve repair and impacts self-reported disability. A concomitant injury, particularly multiple injuries, predicts postoperative cold sensitivity.

Patients' experiences before and after total wrist fusion or total wrist arthroplasty: A qualitative study of patients with wrist osteoarthritis.

INTRODUCTION: For patients with advanced wrist osteoarthritis (OA), total wrist fusion (TWF) is the standard surgical treatment, although total wrist arthroplasty (TWA) has become a plausible motion-preserving alternative. PURPOSE: To explore patients' experiences of living with advanced wrist OA before and after surgery with either a TWF or a TWA. Furthermore, we wanted to explore the expectations of surgery, appraisal of results, and the adaptation strategies used to overcome challenges in everyday life. STUDY DESIGN: Qualitative descriptive. METHODS: A purposive sample of 13 patients with advanced wrist OA surgically treated with TWF (n = 7) or TWA (n = 6) was recruited. Semistructured interviews were conducted and analyzed using qualitative content analysis. RESULTS: Four categories are described: the problematic wrist, the breakpoint, appraisal of the results, and adaptation to challenges in everyday life. Pain relief was the primary expectation of surgery, and involvement in the discussion regarding different surgical options had a positive effect on the appraisal of results. The participants' ability to perform tasks in everyday life appeared to be more related to their level of pain than the range of wrist motion. Successful coping strategies were developed, enabling the participants to become more independent and adapt to challenges in daily life. CONCLUSIONS: Previous surgical experiences, occupation, and amount of wrist motion influenced the participants' expectations, surgical choice with either a TWF or a TWA, and the appraisal of results. The findings contribute valuable insights to both surgeons and hand therapists about the importance of having the patient's individual expectations and needs in focus.

Trapeziectomy for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term.

BACKGROUND: Symptomatic osteoarthritis of the basal joint of the thumb (trapeziometacarpal joint) is a common disabling condition mainly affecting women. It is frequently treated with complete removal of the trapezium with or without soft-tissue interposition. There is limited evidence about whether removal of the trapezium affects stability of the wrist joint and increases the risk of developing wrist osteoarthritis. The aim of this study was to evaluate the long-term prevalence of OA in wrists with previous trapeziectomy compared to wrists with intact trapezium. METHODS: Patients treated with surgery for trapeziometacarpal osteoarthritis at one orthopedic department were invited 10-29 (mean 17) years postoperatively for bilateral radiographic examination. We included radiographs from 114 hands with trapeziectomy and 46 hands with intact trapezium; 38 patients had unilateral trapeziectomy and intact contralateral trapezium. The radiographs were blinded so that the intact trapezium or the trapezial space after trapeziectomy was not visible. The radiographs were then evaluated for radiocarpal/midcarpal osteoarthritis independently by two assessors using three different osteoarthritis grading systems, including the Kellgren-Lawrence classification. The patients rated their satisfaction with the function of each of their hands on a visual analog scale (VAS) from 0 to 100 (higher score better). RESULTS: The prevalence of osteoarthritis ranged from 20 to 26%, mostly mild (Kellgren-Lawrence grade 1). The prevalence of osteoarthritis did not differ between wrists with previous trapeziectomy and those with intact trapezium, both in the whole cohort and in the subgroup of patients with unilateral trapeziectomy and intact contralateral trapezium. There was no significant difference in hand function VAS scores between hands with previous trapeziectomy and hands with intact trapezium in the whole cohort or in the subgroup. CONCLUSIONS: Removal of the trapezium as treatment for basal thumb osteoarthritis does not increase the risk of developing wrist osteoarthritis in the long term.

[Ulnar collateral ligament injury to the thumb].

Instability of the ulnar collateral ligament (UCL) is disabling and can occur at any age as an acute or chronic condition. A medical history and objective examination together with the radiological findings are sufficient to make the diagnosis in the majority of cases. Otherwise, an ultrasound or MRI scan should be considered for the acute and chronic injuries, respectively. The partial injuries are treated non-surgically with immobilisation of the metacarpophalangeal joint, while the complete ruptures require surgery, which is summarised in this review. Chronic UCL injuries with symptomatic osteoarthritis are treated with arthrodesis.

Normative values of the vibration perception thresholds at finger pulps and metatarsal heads in healthy adults.

AIMS: To establish normative values of vibration perception thresholds (VPTs), using multi-frequency vibrometry at finger pulps and at metatarsal heads of the foot in healthy adults. We also aimed to investigate factors that could potentially affect VPTs such as age, sex, height, weight, foot- or handedness and skin temperature. METHODS: VPTs were examined in 924 healthy and randomly selected subjects in the southern Sweden (mean 46 years; 628 women and 296 men). Inclusion criterias were adult subjects (>18 years) in considerable health without diabetes mellitus or other nerve affecting disorders. VPTs were measured at the finger pulps of index and little finger, as well as the first and fifth metatarsal heads of the foot, through multi-frequency vibrometry using the VibroSense Meter® I device. Patient characteristics were recorded and skin temperature was measured before assessment of VPTs. RESULTS: We present normative values of VPTs for a large population of both male and female subjects in various ages. VPTs detoriated as age increased (0.09-0.59 dB per year; p<0.001), i.e. progressing with normal aging. Increasing skin temperature affected VPTs in finger pulps, but not at metatarsal heads, with -0.2 to -1.6 dB, i.e. vibration perception improved with higher temperatures. Height was only found to affect the VPTs of metatarsal heads (250 Hz: 0.42 dB per cm). Sex, weight and handedness did not affect the VPTs. CONCLUSION: We investigated the normative values of VPTs and presented affecting factors as age, skin temperature and height. With these results, VPT testing through multi-frequency vibrometry is enabled to be used in a clinical practice as a diagnostic tool when investigating neuropathy and other neurological disorders.

[Metacarpalfractures].

Metacarpal fractures are common. Stable, extra-articular fractures can often be treated non-operatively with or without closed reduction, splinting and then mobilisation with buddy taping. Unstable or displaced extra-articular fractures, where adequate reduction cannot be maintained, and most intra-articular fractures require osteosynthesis. The goal for any treatment is early mobilisation. Intra-articular fractures, open fractures and certain paediatric fractures can lead to poor functional outcome; hence, referral to a hand surgeon is recommended in this review.

Assessment of a novel computer software in diagnosing radiocarpal osteoarthritis on plain radiographs of patients with previous distal radius fracture.

Objective: Osteoarthritis (OA) has primarily been diagnosed with plain radiographs assessed visually by examiners with regard to joint space width and presence of subchondral sclerosis, cysts and osteophytes. The increasing use of artificial intelligence has seen software developed to examine plain radiographs for diagnosing OA, based on observed OA-associated subchondral bone microarchitecture changes. A software for computerized texture analysis has been developed to identify knee OA. The aim of this study was to assess the software's ability to identify radiocarpal OA. Design: Presence of radiocarpal OA on 63 wrist radiographs of patients with a previous distal radius fracture was assessed independently by two surgeons experienced in assessing radiographs, and classified according to Kellgren-Lawrence (38 OA, 25 no OA). First, the computer software, not previously trained to identify wrist OA, assessed presence of radiocarpal OA on the 63 radiographs. In a second step, 144 labeled wrist radiographs with and without radiocarpal OA was used to train the computer software. Presence of OA on the original 63 radiographs were then reassessed by the software. Sensitivity, specificity and area under the curve (AUC) were calculated to determine the software's ability to discriminate between cases with and without OA. Results: Before training, sensitivity was 76% (95% CI 59-88), specificity 25% (10-47), and AUC 0.50 (0.35-0.65). After training, sensitivity was 46% (29-63), specificity 70% (47-87), and AUC 0.58 (0.43-0.73). Conclusion: The software for computerized texture analysis of subchondral bone developed to identify knee OA could not detect OA of the radiocarpal joint.

[Phalangeal fractures of the hand].

Phalangeal fractures are common in all ages. Stable, extra-articular fractures can be treated non-operatively by closed reduction and buddy taping, while surgical fixation should be considered for unstable and displaced extra-articular fractures and most intra-articular fractures. The treatment should aim at early, active mobilisation in order to achieve the optimal functional outcome. Since intra-articular frac-tures, proximal interphalangeal joint fracture dislocations, open fractures and certain paediatric fractures can lead to poor functional outcome, referral to a hand surgeon is recommended.

Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations: A Long-Term Follow-up.

BACKGROUND: The long-term effect of distal radial fracture malunion on activity limitations is unknown. Between 2001 and 2002, we conducted a prospective cohort study of all patients with distal radial fracture treated with casting or percutaneous fixation in northeast Scania in Sweden. In that original study, the patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at baseline and at 2 years. We performed a long-term follow-up study of patients who were 18 to 65 years of age at the time of the fracture to investigate the association between fracture malunion and activity limitations. METHODS: In this long-term follow-up, patients who had participated in the original study completed the DASH questionnaire and a visual analog scale (VAS) for pain and for satisfaction (scored, 0 [best] to 100) and underwent radiographic and physical examinations at 12 to 14 years after the fracture. We defined malunion as dorsal angulation of ≥10°, ulnar variance of ≥3 mm, and/or radial inclination of ≤15°. We also assessed the presence of radiocarpal osteoarthritis and ulnar styloid nonunion. The primary outcome was the change in DASH score from baseline. Secondary outcomes were DASH, pain, and satisfaction scores, wrist range of motion, and grip strength at the time of the follow-up. RESULTS: Of 85 eligible patients, 63 (74%) responded to the questionnaires and underwent examinations. Malunion was found in 25 patients, osteoarthritis was found in 38 patients, and styloid nonunion was found in 9 patients. Compared with patients without malunion, those with malunion had significantly worse DASH scores from baseline to 12 to 14 years (p = 0.002); the adjusted mean difference was 11 points (95% confidence interval [CI], 4 to 17 points). Similarly, follow-up scores were significantly worse among patients with malunion; the adjusted mean difference was 14 points (95% CI, 7 to 22 points; p < 0.001) for DASH scores, 10 points (95% CI, 0 to 20 points; p = 0.049) for VAS pain scores, and 26 points (95% CI, 11 to 41 points; p = 0.001) for VAS satisfaction scores. No differences were found in range of motion or grip strength. Osteoarthritis (mostly mild) and styloid nonunion had no significant association (p > 0.05) with DASH scores, VAS pain or satisfaction scores, or grip strength. CONCLUSIONS: Patients who sustain a distal radial fracture at the age of 18 to 65 years and develop malunion are more likely to have worse long-term outcomes including activity limitations and pain. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

[Deformities of the finger joints].

Extension of the fingers is a complex act. Boutonnière deformity is defined by flexion at the proximal inter-phalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint due to disruption of the central slip of the extensor tendon. Swan neck deformity is defined by hyperextension at the PIP joint and flexion at the DIP joint, and the pathology is divided into intrinsic, extrinsic, and articular. The deformities are a result of imbalance of the tendons and ligaments in the fingers. Treatment is depending on the underlying cause and includes surgery and non-operative treatment. Functional gain and risk must be realistically assessed.

[Rheumatoid arthritis and hand surgery].

Rheumatoid arthritis results in characteristic deformities of the hand. Medical treatment has undergone a remarkable development. However, not all patients achieve remission or tolerate the treatment. Patients who suffer from deformities and persistent synovitis may be candidates for hand surgery, for which the main goals are pain relief and improved function. Surgical interventions can be divided into prophylactic and therapeutic procedures. The treatment strategy is individual and depends on close collaboration between rheumatologists, hand surgeons and patients.

Cast-treated distal radius fractures: a prospective cohort study of radiological outcomes and their association with impaired calcaneal bone mineral density.

INTRODUCTION: We hypothesized that treating distal radius fractures with cast only or closed reduction and cast is associated with high malunion risk and that the risk is higher in patients with low bone mineral density (BMD). MATERIALS AND METHODS: We prospectively studied 130 patients aged 40 years or older with distal radius fractures treated with cast only (87 patients) or closed reduction and cast (43 patients). Radiographs were obtained before treatment, after reduction (in the closed reduction group), and at 1 year. We measured calcaneal BMD with DXA scanner and calculated T scores. We calculated radiological changes from baseline (initial radiographs in cast only and post-reduction radiographs in closed reduction patients) to 1 year. We assessed the relationship between BMD status (normal, osteopenia or osteoporosis) and baseline-to-1-year worsening in volar tilt, ulnar variance, and radial inclination with analysis of covariance adjusting for baseline radiological values. We used receiver operating characteristic (ROC) analysis to determine the ability of T scores to distinguish patients with severe malunion (dorsal tilt >25° and/or ulnar variance ≥5 mm) from those with less severe or no malunion. RESULTS: In both treatment groups, baseline radiological variables had deteriorated at 1 year, more in the closed reduction group. Compared to patients with normal BMD, those with osteoporosis had significantly greater worsening in volar tilt and radial inclination but did not differ in ulnar variance worsening. Severe malunion was found in 34 fractures (26 %, 15 in cast only group); T scores had a modest ability in distinguishing severe malunion (area under ROC curve 0.67, 95 % CI 0.56-0.78, p = 0.003). CONCLUSIONS: Closed reduction and cast is not an effective treatment for distal radius fractures if radiological graphic outcomes are considered. There is a higher risk of malunion involving dorsal and radial tilt in patients with osteoporosis. Calcaneal BMD measurement may have some benefit in predicting the risk of severe malunion.

Bullosis diabeticorum in median nerve innervated fingers shortly after carpal tunnel release: case report.

Bullosis diabeticorum is a cutaneous manifestation of diabetes mellitus, mainly observed in the lower extremities in patients with longstanding disease. The etiology is unknown, but an association with neurologic or vascular disturbances has been suggested. We have reviewed a case of a 70-year-old man with rapid development of bullae in median nerve innervated fingertips following carpal tunnel release.