Non-steroidal anti-inflammatory drugs (NSAIDs) for trigger finger.

BACKGROUND: Trigger finger is a common hand condition that occurs when movement of a finger flexor tendon through the first annular (A1) pulley is impaired by degeneration, inflammation, and swelling. This causes pain and restricted movement of the affected finger. Non-surgical treatment options include activity modification, oral and topical non-steroidal anti-inflammatory drugs (NSAIDs), splinting, and local injections with anti-inflammatory drugs. OBJECTIVES: To review the benefits and harms of non-steroidal anti-inflammatory drugs (NSAIDs) versus placebo, glucocorticoids, or different NSAIDs administered by the same route for trigger finger. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, CNKI (China National Knowledge Infrastructure), ProQuest Dissertations and Theses, www.ClinicalTrials.gov, and the WHO trials portal until 30 September 2020. We applied no language or publication status restrictions. SELECTION CRITERIA: We searched for randomised controlled trials (RCTs) and quasi-randomised trials of adult participants with trigger finger that compared NSAIDs administered topically, orally, or by injection versus placebo, glucocorticoid, or different NSAIDs administered by the same route. DATA COLLECTION AND ANALYSIS: Two or more review authors independently screened the reports, extracted data, and assessed risk of bias and GRADE certainty of evidence. The seven major outcomes were resolution of trigger finger symptoms, persistent moderate or severe symptoms, recurrence of symptoms, total active range of finger motion, residual pain, patient satisfaction, and adverse events. Treatment effects were reported as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). MAIN RESULTS: Two RCTs conducted in an outpatient hospital setting were included (231 adult participants, mean age 58.6 years, 60% female, 95% to 100% moderate to severe disease). Both studies compared a single injection of a non-selective NSAID (12.5 mg diclofenac or 15.0 mg ketorolac) given at lower than normal doses with a single injection of a glucocorticoid (triamcinolone 20 mg or 5 mg), with maximum follow-up duration of 12 weeks or 24 weeks. In both studies, we detected risk of attrition and performance bias. One study also had risk of selection bias. The effects of treatment were sensitive to assumptions about missing outcomes. All seven outcomes were reported in one study, and five in the other. NSAID injection may offer little to no benefit over glucocorticoid injection, based on low- to very low-certainty evidence from two trials. Evidence was downgraded for bias and imprecision. There may be little to no difference between groups in resolution of symptoms at 12 to 24 weeks (34% with NSAIDs, 41% with glucocorticoids; absolute effect 7% lower, 95% confidence interval (CI) 16% lower to 5% higher; 2 studies, 231 participants; RR 0.83, 95% CI 0.62 to 1.11; low-certainty evidence). The rate of persistent moderate to severe symptoms may be higher at 12 to 24 weeks in the NSAIDs group (28%) compared to the glucocorticoid group (14%) (absolute effect 14% higher, 95% CI 2% to 33% higher; 2 studies, 231 participants; RR 2.03, 95% CI 1.19 to 3.46; low-certainty evidence). We are uncertain whether NSAIDs result in fewer recurrences at 12 to 24 weeks (1%) compared to glucocorticoid (21%) (absolute effect 20% lower, 95% CI 21% to 13% lower; 2 studies, 231 participants; RR 0.07, 95% CI 0.01 to 0.38; very low-certainty evidence). There may be little to no difference between groups in mean total active motion at 24 weeks (235 degrees with NSAIDs, 240 degrees with glucocorticoid) (absolute effect 5% lower, 95% CI 34.54% lower to 24.54% higher; 1 study, 99 participants; MD -5.00, 95% CI -34.54 to 24.54; low-certainty evidence). There may be little to no difference between groups in residual pain at 12 to 24 weeks (20% with NSAIDs, 24% with glucocorticoid) (absolute effect 4% lower, 95% CI 11% lower to 7% higher; 2 studies, 231 participants; RR 0.84, 95% CI 0.54 to 1.31; low-certainty evidence). There may be little to no difference between groups in participant-reported treatment success at 24 weeks (64% with NSAIDs, 68% with glucocorticoid) (absolute effect 4% lower, 95% CI 18% lower to 15% higher; 1 study, 121 participants; RR 0.95, 95% CI 0.74 to 1.23; low-certainty evidence). We are uncertain whether NSAID injection has an effect on adverse events at 12 to 24 weeks (1% with NSAIDs, 1% with glucocorticoid) (absolute effect 0% difference, 95% CI 2% lower to 3% higher; 2 studies, 231 participants; RR 2.00, 95% CI 0.19 to 21.42; very low-certainty evidence). AUTHORS' CONCLUSIONS: For adults with trigger finger, by 24 weeks' follow-up, results from two trials show that compared to glucocorticoid injection, NSAID injection offered little to no benefit in the treatment of trigger finger. Specifically, there was no difference in resolution, symptoms, recurrence, total active motion, residual pain, participant-reported treatment success, or adverse events.

Cyclic Testing of the 6-Strand Tang and Modified Lim-Tsai Flexor Tendon Repair Techniques.

PURPOSE: In this study, we compared the Tang repair technique with the 6-strand modified Lim-Tsai repair technique under cyclic testing conditions. METHODS: Twenty fresh-frozen porcine flexor tendons were randomized into 2 groups for repair with either the modified Lim-Tsai or the Tang technique using Supramid 4-0 core sutures and Ethilon 6-0 epitendinous running suture. The repaired tendons were subjected to 2 stage cyclic loading. The survival rate and gap formation at the repair site were recorded. RESULTS: Tendons repaired by the Tang technique achieved an 80% survival rate. None of the modified Lim-Tsai repairs survived. The mean gap formed at the end of 1000 cycles was 1.09 mm in the Tang repairs compared with 4.15 mm in the modified Lim-Tsai repairs. CONCLUSIONS: The Tang repair is biomechanically stronger than the modified Lim-Tsai repair under cyclic loading. CLINICAL RELEVANCE: The Tang repair technique may exhibit a higher tolerance for active mobilization after surgery with less propensity for gap formation.

Normative data on functional grip strength of elderly in Singapore.

STUDY DESIGN: Cross-sectional study for clinical measurement. INTRODUCTION: Most daily tasks require individuals to exert grip strength with torque, which can be challenging for elderly as their strength diminishes with age. We postulate that to assess the functional capacity of an individual, it is important to evaluate the functional grip strength instead of the maximal static grip strength. PURPOSE OF THE STUDY: The objective of this cross-sectional study is to establish normative data for the functional grip strength of elderly aged 60 years and older in the Singapore population. METHODS: In this study, 233 healthy subjects aged 60 years and older were recruited. Using a custom-made hand strength measurement device, the following measurements were recorded: grip strength at neutral position, grip strength with resistive pronation torque, and grip strength with resistive supination torque. RESULTS: Grip strengths measured for both genders decreased by 13% and 16% for males and females respectively, when pronation torque was exerted, and with supination torque, the strength decreased by 18% and 17% for males and females respectively. CONCLUSION: Normative data for the elderly population in Singapore had been established. The findings from this study can complement the existing ergonomic hand data in designing better assistive tools to improve the independent living of elderly. LEVEL OF EVIDENCE: NA.

A Comparison of K-Wire Versus Screw Fixation on the Outcomes of Distal Phalanx Fractures.

PURPOSE: To compare K-wire and screw fixation of distal phalanx (DP) fractures with respect to union and functional outcome. METHODS: This retrospective study identified patients with DP fractures from a clinic registry taken from 2007 to 2013. Clinical data collected included patient demographics, range of motion (ROM), removal of implant (ROI), and complications. Radiographic data collected included fracture type, location, configuration, fracture displacement, and radiographic union. Statistical analysis was done using a chi-squared test for categorical variables and paired Student's t test for continuous variables. RESULTS: A total of 172 patients with DP fractures were seen in our clinic between 2007 and 2013. Of these, 141 patients were managed conservatively and 31 patients had surgery for 33 DP fractures, of which 12 had K-wire and 21 had screw fixation. Mean union incidence for screw was 100% compared with 83% for K-wire. Time to union was 2.4 months for screw fixation compared with 4.1 months for K-wire fixation. ROM for screw fixation was significantly better (60°) compared with K-wire fixation (45°). ROM for non-transarticular K-wire (46°) was similar to transarticular K-wire (44°). ROI was performed in 52% of patients with screw fixation. Other than fingertip tenderness, which resolved after ROI, no other complications were noted. CONCLUSIONS: Our study showed that the union incidence and time to union for screw fixation were comparable to those for K-wire fixation. Screw fixation of DP fractures resulted in greater distal interphalangeal joint motion compared with K-wire fixation but required removal in half of cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Comparison of Flexor Tendon Repair Between 6-Strand Lim-Tsai With 4-Strand Cruciate and Becker Technique.

PURPOSE: To compare the strength of 6-strand Lim-Tsai repair with 4-strand cruciate and Becker repair, which were done using braided polyblend. We hypothesized that the biomechanical strength of 4-strand repair could be as strong as 6-strand repair because of different flexor tendon repair configurations and uneven load bearing. METHODS: We harvested 60 porcine flexor tendons. A transverse cut at the middle of the tendons was made to perform tendon repair. Six-strand Lim-Tsai repair (consisting of 2 Lim-Tsai locking loops), 4-strand cruciate repair (with 3 cross-stitch loops), and 4-strand Becker repair (with 2 double cross-stitch locking loops) were used for the repairs. The repaired tendons were pulled until failure using a mechanical tester. We recorded ultimate tensile strength, load to 2-mm gap force, stiffness, and mechanism of failure. RESULTS: The Becker repairs had significantly greater tensile strength than the cruciate and Lim-Tsai repairs. The load to 2-mm gap force and stiffness were significantly greater for cruciate repairs and Becker repairs than Lim-Tsai repairs. CONCLUSIONS: The biomechanical strength of 4-strand and Becker repairs could be as strong as 6-strand Lim-Tsai repairs. This study implies that the number of strands crossing the repair site of tendons may not be proportional to the biomechanical strength of flexor tendon repair. CLINICAL RELEVANCE: Hand surgeons are urged to be aware of the biomechanic characteristics of different flexor tendon repair techniques used in the clinical setting.

The dorsal metatarsal artery perforator flap.

Few options exist for the resurfacing of web-space and small soft tissue defects of the dorsum of the distal foot. The study examines the anatomy of the second to fourth dorsal metatarsal arteries in 16 fresh frozen cadavers to determine if the anatomy correlates to that in the hand, permitting the design of local flaps based on perforators of these vessels. A clinical case is also presented, illustrating the efficacy of such a perforator-based flap.Sixteen Asian cadaveric lower limbs were used for this study. The specimens were prepared with latex dye injection. Dissection under loupe magnification was carried out to determine the position and caliber of the cutaneous perforators from the dorsal metatarsal arteries, and the spread of the latex dye in the skin from these cutaneous perforators. One clinical case illustration of this perforator-based flap for distal foot defect resurfacing is presented.In our cadaveric study, each second to fourth dorsal metatarsal artery had between 2 and 5 cutaneous perforators with calibers of 0.5 to 0.7 mm in diameter. The most distal cutaneous perforator was present consistently, always arising between the heads of the respective metatarsals.In conclusion, the vascular anatomy of the second to fourth dorsal metatarsal arteries is similar to that in the hand, thus allowing for the design of reliable perforator-based flaps for distal foot resurfacing.

Biomechanical evaluation of porcine lens capsule with and without nucleus after capsulotomy - Finite element analysis.

Previous studies have shown that the nucleus could offer structural support to the lens capsule. This study investigated the biomechanical performance of porcine lens with and without nucleus for 4 mm, 4.5 mm, 5 mm, 5.5 mm and 6 mm capsulotomy and its potential impact on the stretch ratio of capsular bag when the anterior capsulotomy edge was stretched. Our simulation results showed higher strain for the capsular bag with nucleus, which is crucial for the porcine lens to tolerate more stretch without failure. This simulation could support future study on the optimization of capsulotomy based on patient specific condition, that is, the geometry of lens.

Versatility of the turn-around technique of the lateral arm flap for hand reconstruction.

The lateral arm flap is a popular flap for hand resurfacing. Despite its many advantages, its use is restricted by the available width of the flap. We describe the application of this long and narrow flap in a turn-around manner, greatly increasing its versatility while achieving primary closure of the donor site. The lateral arm flap was designed with extension onto the forearm (extended lateral arm flap) and harvested in the usual manner. During inset, the distal segment of the flap is brought through a 180 degree "U-turn" to lie adjacent to the proximal segment. We analyzed the outcomes of 31 turn-around lateral arm flaps performed between 1988 and 2008. All flaps healed well without any vascular compromise. Reconstruction of defects with a variety of configurations was performed with a maximum flap size of 144 cm. Four patients required split skin grafting to the forearm. Primary closure of the lateral arm donor site was achieved in all patients. In this article, we demonstrate the ease, reliability, and versatility of this simple modification in extending the usefulness of the lateral arm flap in hand reconstruction.

Radial nerve injury during double plating of a displaced intercondylar fracture.

Double-plate fixation is a popular treatment method for intercondylar humeral fractures. Ulnar nerve complications are emphasized, but radial nerve complications are rarely mentioned. We present a case of iatrogenic radial nerve palsy following open reduction and double plating of a supracondylar/intercondylar fracture of the humerus. Before surgery, only a sensory deficit in the radial nerve territory was present, but after surgery, there was a complete motor deficit of the wrist and finger extensors. On exploration, a segment of nerve was found crushed within the reduced lateral condyle fracture site, with a screw from the posteroradial plate going through the nerve. Although rare, radial nerve injury can occur with posteriorly displaced supracondylar/intercondylar humerus fractures. When preoperative signs of radial nerve injury are present, we recommend that the radial nerve be identified and protected during double-plate fixation.

A biomechanical comparison of 3 loop suture materials in a 6-strand flexor tendon repair technique.

PURPOSE: The braided polyblend (FiberWire) suture is recognized for its superiority in tensile strength in flexor tendon repair. The purpose of this study was to compare the biomechanical performance of 3 loop-suture materials used in a locking 6-strand flexor tendon repair configuration: braided polyblend (FiberLoop 4-0), cable nylon (Supramid Extra II 4-0), and braided polyester (Tendo-Loop 4-0). We hypothesized that, using this technique, the braided polyblend suture would give superior tensile strength compared with the other 2 suture materials. METHODS: We divided 30 fresh porcine flexor tendons transversely and repaired each with 1 of the 3 suture materials using a modified Lim-Tsai 6-strand suture technique. We loaded the repaired tendons to failure using a materials testing machine and collected data on the mechanism of failure, ultimate tensile strength, gap strength, and stiffness. RESULTS: Failure mechanisms for the repaired specimens were as follows: the braided polyblend had 50% suture breakage and 50% suture pullout; the cable nylon had 100% suture breakage; and the braided polyester had 80% suture breakage and 20% suture pullout. Specimens repaired with the braided polyblend suture had the highest mean ultimate tensile strength (97 N; standard deviation, 22) and the highest mean gap force (35 N; standard deviation, 7). CONCLUSIONS: This study supports the findings of previous studies showing superior strength of the braided polyblend suture. CLINICAL RELEVANCE: We were able to achieve up to 124 N in ultimate tensile strength and 48 N of gap force with this suture in porcine tendons. This gives greater confidence in starting immediate controlled passive or active rehabilitation after repair of flexor tendon injuries.

Surgical anatomy of the medial sural artery perforator flap.

BACKGROUND: The medial sural (medial gastrocnemius) perforator flap is a thin flap with a long pedicle. It has tremendous potential for applications in a variety of soft-tissue defects. We aimed to further clarify the vascular anatomy of the medial sural region and establish a safe approach for elevation of this flap. METHODS: Ten fresh cadaveric lower limbs were injected and used in this study. We identified the locations and courses of the medial sural artery perforators and correlated them to anatomic landmarks. RESULTS: The medial sural artery divides into two branches, a medial and lateral branch. Correspondingly, musculocutaneous perforators supplying the overlying skin were oriented in two parallel vertical rows, along the course of the lateral or medial branch of the medial sural artery. Two to six perforators were located 6 cm to 22.5 cm from the popliteal crease. Perforators from the lateral row, nearer the posterior midline, were generally larger. In most cases, a large perforator with a superficial, straight intramuscular course could be identified a mean of 10 cm distal to the popliteal crease and an average of 2 cm from the posterior midline. Based on the above findings, we successfully used this flap in five clinical cases. CONCLUSION: Perforators of the medial sural artery were arranged in a medial and a lateral row. Use of perforators from the lateral row, nearer the posterior midline, is preferable as these are usually larger in size. A consistent major perforator could always be identified in all specimens. With increased safety and confidence in flap harvesting, the medial sural artery perforator flap may find wider clinical applications. CLINICAL QUESTION: TherapeuticLevel of Evidence: IV.

Technique of olecranon bone grafting for surgical fixation of scaphoid fractures.

Currently described sources of bone graft, such as iliac crest and distal radius, for supplemental fixation of scaphoid fractures are suboptimal. In our experience, olecranon bone has the advantage of providing a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture, and it also causes less postoperative pain compared to that obtained from iliac crest. Here, we describe our surgical technique for harvest and use of olecranon bone graft for fixation of scaphoid fractures.

Anatomical Study of the Medialis Pedis Flap and its clinical applications in Asian Singaporean Patients.

PURPOSE: The purpose of this study was to revisit the medial plantar artery's anatomy and study its distribution for raising the medialis pedis flap. Several investigators have reported their clinical experience with the use of this flap for reconstruction of soft tissue defects of the hand. However, many have reported difficulty raising the flap due to variations in its arterial anatomy and the confusion that exists with respect to the nomenclature in our literature. METHODS: This study was divided into 2 parts: an anatomic study and clinical application. In the anatomic study, 12 cadaveric feet specimens from 6 patients were injected with latex and barium-gelatin injections and the medial branch of the deep division of the medial plantar artery distribution was studied. We then described the use of a medialis pedis flap in four clinical cases to cover defects of the digits. RESULTS: The anatomic study revealed that the average pedicle length of the deep division of the medial plantar artery was 1.94cm. In the four illustrative clinical cases where the flap was used, the average flap size was 4.5 × 3.75cm. Donor sites were either closed primarily or with skin grafts. The vessels used for this flap were the medial branch of the deep division of the medial plantar artery and venae commitantes, or subcutaneous veins which provided the superficial drainage. All flaps were successful without any significant complications. The study is novel in that it describes the anatomic variability of length of the medial branch of the deep division of the medial plantar artery that exits in nature. CONCLUSIONS: This paper describes the medial branch of the deep division of the medial plantar artery and the anatomic variations that exist in the raising of the medialis pedis flap. We have shown how a medialis pedis flap is an ideal option for reconstructing soft tissue defects of the hand because of its texture, bulkiness and pliability in the context of like for like reconstruction.

Mycobacterium abscessus Hand Infections in Immunocompetent Fish Handlers: Case Report.

Mycobacterium abscessus hand infections are rare and usually occur in immunocompromised patients or after injection with contaminated injectables. This article describes 2 cases of M abscessus infection of the hand in otherwise healthy fish handlers. Mycobacterium abscessus can cause severe chronic tenosynovitis even in immunocompetent patients and should be suspected alongside the more common M marinum as a cause of nontuberculous mycobacterial hand infections in patients with aquatic and fish exposure.

Biomechanical comparison of vertical suture techniques for repairing radial meniscus tear.

PURPOSE: The aim of this study was to (1) develop suture techniques in repairing radial meniscal tear; (2) to compare the biomechanical properties of the proposed repair techniques with the conventional double horizontal technique. METHODS: Thirty-six fresh-frozen porcine medial menisci were randomly assigned into four groups and a complete tear was made at the midline of each meniscus. The menisci were subsequently repaired using four different repair techniques: double vertical (DV), double vertical cross (DVX), hybrid composing one vertical and one horizontal stitch, and conventional double horizontal (DH) suture technique with suturing parallel to the tibia plateau. The conventional double horizontal group was the control. The repaired menisci were subjected to cyclic loading followed by the load to failure testing. Gap formation and strength were measured, stiffness was calculated, and mode of failure was recorded. RESULTS: Group differences in gap formation were not statistically significant at 100 cycles (p = .42), 300 cycles (p = .68), and 500 cycles (p = .70). A trend was found toward higher load to failure in DVX (276.8 N, p < .001), DV (241.5 N, p < .001), and Hybrid (237.6 N, p < .001) compared with DH (148.5 N). Stiffness was also higher in DVX (60.7 N/mm, p < .001), DV (55.3 N/mm, p < .01), and Hybrid (52.1 N/mm, p < .01), than DH group (30.5 N/mm). Tissue failure was the only failure mode observed in all specimens. CONCLUSION: Our two proposed vertical suture techniques, as well as the double vertical technique, had superior biomechanical properties than the conventional technique as demonstrated by higher stiffness and higher strength.

Trapeziectomy and carpal collapse.

PURPOSE: Trapeziectomy for the treatment of trapeziometacarpal (TM) osteoarthritis (OA) disrupts the scaphotrapezium-trapezoidal ligament complex and may be associated with carpal collapse in a subset of patients in the form of nondissociative dorsal intercalated segment instability (DISI). The purpose of this study was to examine the clinical and radiographic outcomes of trapeziectomy, documenting the incidence of postoperative carpal collapse, and to determine whether this outcome is correlated with preoperative radiographic findings. METHODS: A retrospective chart and radiographic review was performed on 33 wrists having trapeziectomy from January 1999 to January 2006. Three surveys were administered to patients after surgery to assess subjective levels of pain, function, and satisfaction. The Wilcoxon signed-rank test was used to determine significant differences in radiographic angles, and McNemar's chi-square test was used to determine significant differences in the frequency of a DISI finding. RESULTS: Stage IV disease was present in 58% of wrists; all wrists were followed up at a mean of 10.5 months after surgery. The mean postoperative change in the radiolunate angle was 4.4 degrees of increased dorsal tilt. Radioscaphoid angles changed after surgery by a mean of 6.3 degrees of increased extension. The frequency of DISI as measured by the radiolunate angle increased significantly, from 27% before surgery to 50% after surgery. Scaphotrapezium-trapezoidal arthritis was observed in 58% of wrists; within this subset, DISI was present in 39% before surgery and 62% after surgery. Those patients with a DISI deformity were significantly less satisfied following surgery than those without this finding. CONCLUSIONS: Patients having trapeziectomy for treatment of TM OA may be at risk for the development of carpal instability. This instability may manifest through either a DISI posture of the wrist or abnormal extension of the scaphoid in the presence of a normal scapholunate angle. The presence of stage IV TM OA may be correlated with an increased incidence of carpal instability after surgical intervention. These radiographic findings are mirrored by a trend toward increased levels of pain and decreased levels of function and satisfaction in those patients with evidence of DISI. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Asymmetric 6-Strand Flexor Tendon Repair - Biomechanical Analysis Using Barbed Suture.

Background: This study investigates the biomechanical performance of the Asymmetric flexor tendon repair technique using barbed suture. The Asymmetric repair technique using monofilament nylon suture was previously reported to have a higher tensile strength than the modified Lim-Tsai repair technique, but its repair stiffness and load to gap force were significantly lower. There is hence an unmet need to improve this technique and the substitution of nylon suture with barbed sutures may be the solution. Methods: Two groups consisting of 10 porcine tendons each were repaired with the six-strand Asymmetric repair technique using V-Loc® 3-0 and Supramid® 4-0 respectively. The repairs were subjected to a mechanical tester for static testing. The ultimate tensile strength, load to 2 mm gap force, repair stiffness, time taken to complete a repair and failure mechanism of the repairs were recorded and analyzed. Results: All the repairs using V-Loc® 3-0 sutures had significantly higher median values of ultimate tensile strength (64.1 N; 56.9 N), load to 2 mm gap force (39.2 N; 19.7 N), repair stiffness (6.4 N/mm; 4.7 N/mm) and time taken to complete a repair (9.4 mins; 7.7 mins). All the repairs using V-Loc® sutures failed by suture breakage while 80% of repairs using Supramid® sutures failed by suture pullout. Conclusions: The use of the barbed sutures in the Asymmetric repair technique, whilst more time consuming, has shown promising improvement to its biomechanical performance (i.e. better ultimate tensile strength, stiffness and resistance to gap formation).

Positive Ulnar Fovea Sign - Audit of Patient Outcomes Following Nonsurgical and Surgical Management.

Background: Patients with ulnar-sided wrist pain and positive ulnar fovea sign are usually treated nonsurgically before surgical options are considered. However, the outcomes of nonsurgical management are unknown. Many of these patients also have unstable distal radioulnar joint, but there has been no comparison between the outcomes of these patients with stable and unstable distal radioulnar joint. The objectives of this study are to (1) determine the outcomes of nonsurgical and surgical treatment of patients with positive ulnar fovea sign, and (2) compare the outcomes of patients with stable and unstable distal radioulnar joint. Methods: A retrospective analysis of the outcomes of patients with ulnar sided wrist pain and positive fovea sign was performed from March 2009 to December 2014. Outcomes were measured based on patient-reported pain improvement, grip strength and range of motion of the affected wrist before and after treatment. A total of 100 wrists in 98 patients were reviewed. Results: 54% of wrists managed nonsurgically experienced pain improvement. 83% of wrists managed surgically experienced pain improvement. The mean grip strength increased by 2.8 kg and 2.7 kg, while the range of motion decreased by 14° and 5° after nonsurgical and surgical treatment respectively. When comparing patients with stable and unstable distal radioulnar joint, there were statistically more wrists with unstable distal radioulnar joint that experienced pain improvement after treatment. Conclusions: The study showed that there is a role for nonsurgical treatment for wrists with positive ulnar fovea sign with more than half of the patients experiencing pain improvement. We also found that positive ulnar fovea sign patients with unstable distal radioulnar joint had better pain outcomes compared to those with stable distal radioulnar joint.

Clinical Outcomes of Zone 2 Flexor Tendon Repairs Using the Modified Lim/Tsai Technique.

BACKGROUND: The single looped suture modified Lim/Tsai technique is widely used for flexor tendon repairs. It has been shown to possess better biomechanical properties and require less repair time per tendon as compared to the double looped suture original Lim/Tsai technique. However, there is no clinical data on the modified technique. METHODS: The retrospective study included zone 2 flexor tendon repairs made using the modified Lim/Tsai technique from January 2008 to December 2014. Clinical outcome was assessed using the revised Strickland and Glogovac criteria, which categorises repairs based on the total active motion of the repaired digit. RESULTS: Sixty-two patients with 74 digits were included. The overall mean total active motion was 122°. The overall satisfactory outcome of the modified Lim/Tsai technique was 81.1%. The rupture rate of the modified Lim/Tsai technique was 2.7%. Using multivariate linear regression model, we found that outcomes were negatively influenced by subzone 2C and crush/saw injuries, but not by concomitant neurovascular injuries or post-operative follow-up duration. CONCLUSIONS: Based on this retrospective study of patients with zone 2 flexor tendon injuries, the clinical outcomes of modified and original Lim/Tsai techniques are comparable. As such, there is no clinical evidence favouring one over the other.