Arthroscopic Capsular Shrinkage Is Safe and Effective in the Treatment of Midcarpal Instability in a Pediatric Population: A Single-Center Experience of 51 Cases.

Objective Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series. Methods In a tertiary hand center for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analog scale (VAS) at rest and with load, and grip strength. Data were used to determine the safety and efficacy of this treatment in pediatric and adolescent patients. Results Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone ( p = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest ( p = 0.02) and VAS with load ( p = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion ( p = 0.02), extension ( p = 0.03), and radial deviation ( p = 0.01). Conclusion ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist center. Level of Evidence This is a Level IV study.

Early MRI for Pediatric Wrist Injuries-Prospective Case Series of 150 Cases.

Background Pediatric carpal injuries are a clinical challenge due to their non-specific clinical features and occult nature on plain radiography. We hypothesized that early magnetic resonance imaging (MRI) will allow prompt diagnosis and treatment stratification, and that distal pole fracture of the scaphoid requires a shorter duration of immobilization. This study aims to assess the injury pattern and clinical outcomes of under-16-year-olds treated with acute post-traumatic wrist injuries in accordance with the unit's protocol. Methods All patients under the age of 16 years treated for suspected pediatric wrist injuries in our tertiary pediatric hand and upper limb service were included. Prospectively collected data included patient demographics, radiological findings, treatment and adherence to the unit's protocol. Results There were 151 patients with a mean age of 12 years. The majority (72%) had occult bony injury with radiological evidence of fracture on MRI. The sensitivity and specificity of plain film radiography were 42.7% and 71.4%, respectively. Almost one in four patients benefitted from early MRI demonstrating no injuries, permitting early mobilization and discharge. The scaphoid was the most commonly injured carpal bone. Non-displaced fractures of the distal pole of the scaphoid in patients over 10 years old were treated with 4 weeks' immobilization with no adverse outcome. Conclusion Standardized care in our unit has yielded good results with low complication rate and fewer hospital appointments. Our results support the routine early use of MRI and a shorter duration of immobilization in fracture of the distal pole of the scaphoid at 4 weeks. Level of Evidence This is a level IV, case series study.

Role of Wrist Arthroscopy in Juvenile Inflammatory Arthritis.

Background and Purposes The wrist is the fourth most common joint to be involved in juvenile inflammatory arthritis (JIA), which is a common rheumatological condition affecting children. Wrist arthroscopy is well established in rheumatoid arthritis, but remains unexplored in JIA. The aim of this study is to investigate the role of wrist arthroscopy in JIA, with focus on those who are refractory to medical management. Methods This is a prospective observational study, including consecutive patients with JIA undergoing arthroscopy between January 2016 and December 2020. Those over the age of 18 years and those with other rheumatological diagnoses were excluded. Data including pre-, intra-, and postoperative variables, demographics, and patient-reported outcomes were collated and are reported using standard measures. Results A total of 15 patients underwent arthroscopy ( n = 20 wrists). Synovitis was noted in all wrists on arthroscopy and synovectomy was performed in all cases. Other procedures were performed as indicated during the procedure. The median follow-up duration was 11.3 (interquartile range [IQR] 8.1-24.2) months. Median reduction of 4 (IQR 2.25-6) points on the Visual Analogue Score for pain on loading was noted postoperatively. Grip strength was improved in n = 11/20 wrists and functional improvement was noted in n = 18/20 wrists. Restriction of range of motion was achieved with a shrinkage procedure in patients with hypermobile joints. There were no postoperative complications, and no patients were lost to follow-up. Conclusion In experienced hands, wrist arthroscopy is feasible, safe, and efficacious in the management of JIA, among patients who are refractory to medical management. Level of Evidence This is a Level II study.

Effective Treatment of Simultaneous Distal Radius and Scaphoid Fractures.

Background There is an increasing trend for most surgeons to choose open reduction and internal fixation of simultaneous distal radius and scaphoid fractures; however, it is not clear if there is any evidence to support this. Case Description The purpose of this systematic review was to investigate the evidence for management of simultaneous distal radius and scaphoid fractures. Literature Review We performed searches of the EMBASE and MEDLINE databases (CRD42020167403). We included a total of 20 studies, involving 178 patients with 182 simultaneous fractures of the distal radius and scaphoid. The distal radius fractures were mostly intra-articular (112/182). The scaphoid fractures were mostly undisplaced (120/148) and at the scaphoid waist (152/178). All distal radius fractures went on to unite, and just 2 of 182 scaphoid fractures went on to nonunion. All included studies were retrospective case series, and therefore all were found to have a critical risk of bias due to confounding. The union rate for both the distal radius and scaphoid fractures is high with both operative and nonoperative treatments. Clinical Relevance Although there are no comparative studies to evaluate the most effective treatment, there is evidence to support operative management. Level of Evidence This is a Level IV, systematic review study.

Trapeziectomy and Abductor Pollicis Longus Suspensionplasty Combined with Extensor Pollicis Brevis Tenodesis for Management of Thumb Basal Joint Osteoarthritis and Metacarpophalangeal Hyperextension.

Metacarpal joint hyperextension is common cause of postoperative dissatisfaction after trapeziectomy in the management of basal thumb osteoarthritis. The senior author uses this technique to address this biomechanical problem at the time of trapeziectomy.

Scaphoid Fractures below the Age of 10: Case Series and Review of the Literature.

Background Scaphoid fractures are relatively uncommon in children, especially below the age of 10 due to the ossification of the scaphoid bone, which starts around 4 to 6 years of age and continues until 13 to 15 years of age, where pediatric scaphoid fractures peak. This makes the diagnoses challenging in this age group. Methods The primary aim of this study was to analyze prospectively collected data in managing scaphoid fractures. All cases in children up to the age of 10 years, treated in a tertiary pediatric hand and upper limb from January 2014 to June 2018 were included. Parameters studied were patient demographics, clinical presentation, mechanism of injury, investigations, type of fracture, associated injuries, treatment offered, outcomes and complications. The secondary aim was to review the literature due to the limited knowledge about these fractures in these low age groups. Results A total of 23 patients with documented scaphoid fractures in children up to the age of 10 years were found. Final diagnosis in all these patients was done with magnetic resonance imaging (MRI). The mean age was 9.8 years, with female preponderance. Scaphoid waist was the most common location. Five patients had associated fractures of the capitate and one patient had associated second metacarpal base fracture. All patients were managed nonoperatively. The average time of immobilization was 6.6 weeks (range: 4-10 weeks). A majority of patients had minor symptoms after the fracture, most likely due to the immobilization time. Conclusion Scaphoid fractures are rare in the pediatric population up to the age of 10. MRI is most often needed to confirm diagnosis. Nonoperative management of most scaphoid fractures in this age group is safe and feasible with no significant long-term morbidity. Surgical management of scaphoid fractures might be required in very selected cases. Level of Evidence This is a Level IV study.

The management of acute fracture dislocations of proximal interphalangeal joints: a systematic review.

LEVEL OF EVIDENCE: III.

Pediatric Scaphoid Nonunions: A Case Series, Review of the Literature, and Evidence-Based Guidelines.

Background Scaphoid fractures represent less than 3% of hand and wrist fractures in the pediatric population. Nonunions are very rare. We present a case series ( n = 18) of nonunions in skeletally immature children and adolescents. We further present a review of the literature on pediatric scaphoid nonunions. Materials and Methods We reviewed the literature by searching the main databases on pediatric scaphoid nonunions, but to identify factors that lead to nonunion, we also searched for databases on scaphoid fractures. Seventy articles were found for the period between 1961 and 2019, all with level 4/5 evidence. Results The nonunion rate of pediatric scaphoid fractures in the literature is on average 1.5%, occurring mostly as a result of missed or underdiagnosed injuries, similar to our presented case series. Half ( n = 9) of the injuries in our case series were missed initial injuries, leading to scaphoid nonunions and half developed nonunions after initial treatment. We found excellent outcomes and with surgical and nonoperative management, with few complications. Not surprisingly, the duration of immobilization is longer with nonoperative management. Conclusions Based on the literature, we recommend a period of nonoperative management before surgery in undisplaced nonunions. In displaced nonunions, open reduction and internal fixation ± bone grafting is necessary. In pediatric scaphoid fractures, similar to adult cases, we identified that suspicious scaphoid fractures should be considered for initial immobilization, and repeat X-rays and early magnetic resonance imaging (MRI) or computed tomography (CT) scans should be considered at follow-up. Immobilization time and type of plaster should be appropriate in relation to the fracture site, similar to the adult scaphoid fracture. Level of Evidence This is a Level IV study.

Open Versus Arthroscopic Repair of 1B Ulnar-Sided Triangular Fibrocartilage Complex Tears: A Systematic Review.

Background: Peripheral 1B tears of the triangular fibrocartilage complex (TFCC) can result in distal radioulnar joint (DRUJ) instability. In the context of associated DRUJ instability, combined evidence supports successful outcomes for peripheral tear repair. Methods: The aim of this systematic review (SR) was to compare the surgical treatment of 1B TFCC tears via arthroscopic versus open methods of repair. The primary outcome measure was restored DRUJ stability. The secondary outcome measures included patient-reported outcomes and clinical outcome measures. An electronic database search of Ovid Embase, PubMed, and the Cochrane Central Register of Controlled Trials was performed to cover a 20-year period. Two authors independently screened records for eligibility and extracted data. Results: Only 3 studies met the strict inclusion criteria, highlighting the poor evidence base for TFCC 1B repairs. Hence, a "secondary analysis" group was developed with modified inclusion criteria which included a further 7 studies for analysis. Pooled data from the primary and secondary analysis groups demonstrated that postoperative DRUJ stability was achieved following open repair in 84% (76/90) of cases and following arthroscopic repair in 86% (129/150) of cases. Conclusions: This SR demonstrates a current lack of high-quality evidence required to draw firm conclusions on the merits of arthroscopic versus open repair of 1B TFCC tears. There is no scientific evidence to suggest superiority of one technique over the other, albeit some surgeons and authors may express a strong personal view.

No long-term risk of wrist osteoarthritis due to subchondral haematomas in distal radial fractures.

OBJECTIVE: The objective of this study of distal radius fractures was to determine if a subchondral haematoma in an unfractured compartment predicts secondary osteoarthritis. METHODS: In 1995-1997, 41 patients, 22 women, a median age of 41 years (20-57 years) with a displaced distal radius fracture underwent diagnostic wrist arthroscopy in addition to the fracture treatment. In 12 patients (7/12 women), subchondral haematomas were identified in a joint compartment not involved in the fracture. RESULTS: At 13-15 years, 37 patients were still alive. Twenty-eight patients attended the follow-up and 8/28 had had a subchondral haematoma within an uninjured compartment at the time of arthroscopy. The range of motion at 13-15 years was impaired in the injured wrist, but unrelated to the presence of a subchondral haematoma. The mean grip strength in patients with subchondral haematoma was 80% of the contralateral, compared to 78% in patients without. No correlation was found between the presence of a subchondral haematoma at arthroscopy and the development of radiographic osteoarthritis in the long term. CONCLUSION: The presence of a subchondral hematoma in an uninjured compartment at the time of fracture did not alter the long-term clinical or radiographic outcome after a distal radius fracture.

Arthroscopic Evaluation of Associated Soft Tissue Injuries in Distal Radius Fractures.

The best outcome in distal radius fractures is achieved if anatomy is restored, in particular the intra-articular congruity. This is achieved partly with improved fixation, such as using volar locking plates, and partly by using an arthroscopy-assisted reduction and fixation technique. In addition to improving the intra-articular congruity, associated ligament and chondral injuries can be detected and treated. This article outlines various associated injuries with suggested management in a stepwise fashion. It is hoped that overall outcomes will be improved once patient-related and treatment-related factors have been evaluated and previously undetected associated ligament injuries have been found and treated.

Rheumatoid hand surgery: is there a decline? A 22-year population-based study.

BACKGROUND: Rheumatoid arthritis (RA) is the most common idiopathic inflammatory arthritis affecting 0.8 % of the population. It can cause significant hand and wrist damage and dysfunction. Recent advances in anti-rheumatic treatments have the potential to decrease the prevalence of hand deformities in patients with RA. Our aim was to investigate whether there has been a decline over 22-years in the number of hand surgical procedures being undertaken for patients with RA and whether this correlates with the introduction of new anti-rheumatic therapies. METHODS: We performed a retrospective, population-based (Derbyshire) study of all patients with RA who underwent hand surgery at the Pulvertaft Hand Centre from 1990 to 2012. Index procedures included (1) teno-synovectomy and soft tissue procedures, (2) wrist arthrodesis/arthroplasty and (3) finger arthrodesis. RESULTS: A total of 297 procedures were performed in 153 Derbyshire patients with RA over the 22-year period, with mean age at surgery 59 years (range 24-88 years). The female to male ratio was 2.5:1. The overall trend showed a peak in 2004 and a subsequent decline thereafter. This coincides with an increasing tendency by local rheumatologists to introduce earlier and more intensive conventional disease-modifying drugs and biological therapies for more resistant disease. CONCLUSIONS: There has been a decline in the number of hand surgery procedures being performed on patients with RA during our 22-year population-based study. It indicates that medical treatments and strategies have been successful at preventing disease progression.

Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data.

PURPOSE: Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study was a 5-year noninterventional follow-up study to determine long-term efficacy and safety of collagenase clostridium histolyticum (CCH) treatment for Dupuytren contracture. METHODS: Patients from previous CCH clinical studies were eligible. Enrolled patients were evaluated annually for contracture and safety at 2, 3, 4, and 5 years after their first injection (0.58 mg) of CCH. In successfully treated joints (≤ 5° contracture following CCH treatment), recurrence was defined as 20° or greater worsening (relative to day 30 after the last injection) with a palpable cord or any medical/surgical intervention to correct new/worsening contracture. A post hoc analysis was also conducted using a less stringent threshold (≥ 30° worsening) for comparison with criteria historically used to assess surgical treatment. RESULTS: Of 950 eligible patients, 644 enrolled (1,081 treated joints). At year 5, 47% (291 of 623) of successfully treated joints had recurrence (≥ 20° worsening)-39% (178 of 451) of metacarpophalangeal and 66% (113 of 172) of proximal interphalangeal joints. At year 5, 32% (198 of 623) of successfully treated joints had 30° or greater worsening (metacarpophalangeal 26% [119 of 451] and proximal interphalangeal 46% [79 of 172] joints). Of 105 secondary interventions performed in the successfully treated joints, 47% (49 of 105) received fasciectomy, 30% (32 of 105) received additional CCH, and 23% (24 of 105) received other interventions. One mild adverse event was attributed to CCH treatment (skin atrophy [decreased ring finger circumference from thinning of Dupuytren tissue]). Antibodies to clostridial type I and/or II collagenase were found in 93% of patients, but over the 5 years of follow-up, this did not correspond to any reported clinical adverse events. CONCLUSIONS: Five years after successful CCH treatment, the overall recurrence rate of 47% was comparable with published recurrence rates after surgical treatments, with one reported long-term treatment-related adverse event. Collagenase clostridium histolyticum injection proved to be an effective and safe treatment for Dupuytren contracture. For those receiving treatment during follow-up, both CCH and fasciectomy were elected options. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Arthroscopically diagnosed scapholunate ligament injuries associated with distal radial fractures: a 13- to 15-year follow-up.

PURPOSE: To evaluate the natural history of untreated complete or partial scapholunate (SL) ligament tears associated with displaced distal radius fractures. METHODS: Between 1995 and 1997, 51 consecutive patients aged < 60 years with displaced distal radius fractures were examined arthroscopically to assess for concomitant soft tissue injuries. Thirty-two of 51 patients had an SL ligament tear, 10 had a complete tear (Lindau grade 3), and 22 had a partial tear (Lindau grades 1 and 2). Thirty-two patients had AO type-C fractures, 3 had type-B fractures, and 16 had type-A fractures. In 2010, 47 of the 51 patients were still alive, and they were invited for an interview, clinical examination, and radiography. RESULTS: Thirty-eight of the 51 original patients participated in the long-term follow-up. Mean grip strength was 83% relative to the contralateral hand in patients with a complete tear, as compared with 92% in patients with partial or no SL tears (nonsignificant). Median Disabilities of the Arm, Shoulder, and Hand questionnaire score was 2 (range, 0‒55) for complete SL tears, compared with 9 (range, 0‒70) for the others (nonsignificant). No differences were found regarding visual analog scale pain or wrist motion/forearm rotation. None of the patients developed a static SL dissociation or a SL advanced collapse wrist. CONCLUSIONS: No major differences were found in the subjective, objective, or radiographic outcome after a complete (grade 3) or partial (grade 1 or 2) SL untreated tear associated with displaced distal radius fracture. It should be noted that none of the patients had a grade 4 SL tear, which may have a different outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Costs analysis and comparison of usefulness of acute MRI and 2 weeks of cast immobilization for clinically suspected scaphoid fractures.

BACKGROUND AND PURPOSE: Fractures of the scaphoid are often not detected on initial plain radiographs. Conventional management of clinically suspected scaphoid fractures is cast immobilization for 2 weeks and then reassessment. Early MRI is a diagnostic alternative. We compared the cost and usefulness of the early MRI diagnostic strategy with that of conventional management. PATIENTS AND METHODS: This prospective pseudo-randomized study included patients between 18 and 49 years of age who attended Bergen Accident and Emergency Department, Bergen, Norway during 1 year in 2009-2010, after sustaining an acute wrist trauma in the previous week and with a clinically suspected scaphoid fracture. 61 patients were investigated with acute MRI, while 63 patients received standard treatment as a control group. We used cost-minimization analysis to estimate the cost of the 2 patient groups. RESULTS: Concerning cost, there were no statistically significant differences in the total direct medical costs or in indirect costs between the groups. Concerning usefulness, patients in the MRI group without a fracture (n = 35) used a cast for fewer days (mean 1 day) than patients in the control group with no fractures (n = 52) (mean 14 days; p < 0.001). They had less than half the number of days on sick leave than patients in the control group (mean 7 days vs. 15 days; p = 0.002). INTERPRETATION: In a Norwegian setting, an early MRI was of value in patients with clinically suspected scaphoid fracture and normal plain radiographs.

Grip strength ratio: a grip strength measurement that correlates well with DASH score in different hand/wrist conditions.

BACKGROUND: Grip strength correlates with personal factors such as gender, age and nutritional status and has a good inter-rater reliability. It reflects fairly well how much people can use their hands.The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure 3 is a 30-item, self-report, questionnaire that reflects the patients' opinion on their disability due to upper-limb disorders. We assessed if grip strength and grip strength ratio correlate with DASH score. METHODS: In 3 groups (20 healthy volunteers, 17 patients after distal radius fractures, 12 patients with different hand/wrist conditions) grip strength and DASH scores (items 1-21, 22-30 and total) were assessed. To exclude personal factors grip strengths in the injured or non-dominant hand and grip strength ratios (grip strength in the injured or non-dominant hand divided by grip strength in the non-injured or dominant hand) were assessed too. Results were analyzed groups using Pearson Correlation Coefficients and with a multivariate ANOVA. RESULTS: Grip strength ratio was 0.97 in healthy volunteers, 0.52 in patients after distal radius fracture and 0.74 in patients with various other hand/wrist disorders.Significant correlations were found between the grip strength ratio and DASH as well as DASH subsections in all groups and between DASH scores and grip strength in some. The correlations between the ratio of the grip strength (GSR) and DASH were much stronger than the correlation between grip strength and DASH. This emphasizes the value of the GSR. Age showed no correlation with grip strength ratio using a multivariate ANOVA. CONCLUSION: Grip strength ratio correlates well with the DASH score in different hand and wrist conditions. It is a valuable tool to assess patients that speak a different language and have problems with the non-dominant hand and probably easier to follow over time than the DASH score, which is time consuming to fill in and process.

Clinical scaphoid score (CSS) to identify scaphoid fracture with MRI in patients with normal x-ray after a wrist trauma.

INTRODUCTION: The aim of this study was to compare a combination of three commonly used tests to identify scaphoid fractures with MRI in patients with normal x-ray after a wrist trauma. PATIENTS AND METHODS: This prospective MRI study included patients between 18 years and 49 years, who attended the Emergency Department, Bergen, Norway after sustaining an acute wrist trauma within the previous week. Initial x-rays of the wrist were normal. MRI was done within a median of 1 day after the trauma. The study period lasted 1 year. The patients were examined with three commonly used clinical scaphoid tests; tenderness in the anatomical snuffbox with the wrist in ulnar deviation (3 points), tenderness over the scaphoid tubercle (2 points) and pain upon longitudinal compression of the thumb (1 point). The clinical scaphoid score (CSS) is a sum of these points, which was compared with MRI verified fracture of the scaphoid. RESULTS: We included 154 patients with wrist sprain and normal x-rays; 13 had occult scaphoid fracture. A CSS of 4 or more was the only statistically significant 'cut-off' value to identify occult scaphoid fractures (p<0.05). Diagnostic sensitivity increased with more experienced Emergency Department doctors. CONCLUSIONS: If a patient with wrist pain after injury and normal x-ray has a CSS≥4 (pain in the anatomical snuffbox in addition to pain at scaphoid tubercle or longitudinal compression or both) we recommend MRI. A CSS <4 has a negative predictive value of 96%, which makes scaphoid fracture unlikely.

Early prognostic factors in distal radius fractures in a younger than osteoporotic age group: a multivariate analysis of trauma radiographs.

BACKGROUND: Treatment of distal radius fractures in patients of a younger than osteoporotic age is complex, because they often are the result of a high-energy trauma and have intra-articular fractures and associated injuries. As yet no fracture classification exists that predicts outcome. Our aim was to find the earliest possible prognostic factor by testing which radiological parameter on the trauma radiograph would have the greatest impact on clinical outcome in a younger than osteoporotic age group. METHODS: We assessed 66 patients (34 F) with unilateral fractures of the distal radius from a non-Osteoporotic age group. The median age was 42 years, (10th -90th percentile 20-54). Pre-reduction antero-posterior and lateral wrist radiographs were obtained and fracture pattern, radiocarpal joint surface tilt, radial length, radial inclination and ulnar variance were measured. Clinical outcome was assessed with the subjective part as well as the complete modified Gartland and Werley score. Multivariate analysis of those parameters was performed to assess which radiological parameter would best predict outcome. RESULTS: It was found that post-traumatic ulna + (>2 mm) was the single factor that significantly correlated with a bad outcome. An intra-articular fracture pattern may also be a strong marker; however this was not statistically significant (RR 95% conf interval 0.94 - 20.59). CONCLUSIONS: The present study showed that post-traumatic ulna + is the most important factor in predicting bad outcome in non-osteoporotic patients, but that especially intra-articular fractures and to a lesser extent dorsal tilt may be of importance too.