Velocity drop in anconeus epitrochlearis-associated cubital tunnel syndrome

The anconeus epitrochlearis (AE) muscle is a common anatomical variation in the cubital tunnel retinaculum of the elbow with an incidence of up to 28%; it is one cause of compressive ulnar neuropathy. In this study, we report the significance of preoperative recognition of AE-associated cubital tunnel syndrome, based on the grade of velocity drop of the compressed ulnar nerve in electrophysiological studies. Twenty-two cases with idiopathic cubital tunnel compression (CTC) were retrospectively analyzed; AE was present in 6 cases. Velocity drop of the ulnar nerve was calculated by dividing the difference in velocity (m/s) by distance (cm); the results were classified into the following grades: + (0-2.99 m/s per cm) and ++ (< 3.00 m/s per cm). Categorical data were compared using Fisher's exact test; the Mann-Whitney U test was used to determine statistical significance of ordinal data. In patients with AE-associated CTC, 3 of the 6 (50%) cases had grade ++ velocity drop. In comparison, only 1 patient of the 16 non-AE cases (6%) had grade ++ velocity drop (P = .046). Preoperative nerve velocity conduction studies that show grade ++ velocity drop (< 3.00 m/s per cm) in ulnar nerve are highly suggestive of the presence of AE

Type IIb bony mallet finger: is anatomical reduction of the fracture necessary?

One-third of all mallet fingers are associated with a fracture. Many different management strategies have been described. Some authors recommend nonsurgical management for all mallet fractures. In contrast, others suggest mandatory open reduction and internal fixation for bony mallet injuries with a large displaced dorsal fragment and associated distal interphalangeal (DIP) joint subluxation. We retrospectively studied 3 cases of a mallet fracture with a large displaced dorsal fragment and subsequent DIP joint subluxation managed with closed reduction using only percutaneous pinning of the DIP joint. All 3 patients had satisfactory pain-free and functional clinical outcomes at their particular follow-up (4, 6, or 19 months). Closed reduction and internal fixation of the subluxated joint using only Kirschner wires produced satisfactory outcomes for the 3 type IIb bony mallet fingers. Anatomical reduction of the fracture may be unnecessary in patients such as those in our case series. One aim of this pilot study is to justify larger, prospective studies

Dorsal fracture-dislocations of the proximal interphalangeal joint: evaluation of closed reduction and percutaneous Kirschner wire pinning

BACKGROUND The purpose of this study is to evaluate the outcome of closed reduction and percutaneous Kirschner wire pinning in acute dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint. METHODS Eight men and one woman were treated with closed reduction and percutaneous Kirschner wire pinning by one orthopaedic surgeon. The ring finger was injured in six patients, the small finger in two patients and the middle finger in one patient. The mean joint surface involvement was 36 % (range, 26-49 %). The Kirschner wires were removed after an average of 28 days (range, 24-37 days). RESULTS All patients demonstrated a painless, but fusiform, swollen PIP joint after a mean follow-up of 6.5 months. The average flexion of the PIP joint was 106° (range, 80-110), and the average extension of the PIP joint was 4° short of full extension (range, 10 hyperextension-15 flexion contracture). All patients had a concentrically reduced PIP joint with a healed fracture on radiographs. Two patients had radiographic evidence of degenerative changes, but were asymptomatic. One patient developed a superficial pin track infection, which quickly resolved with a short course of antibiotics, and avascular necrosis affecting one of the condyles of the proximal phalanx. CONCLUSIONS In agreement with previous studies, closed reduction and percutaneous Kirschner wire pinning in dorsal fracture-dislocations of the PIP joint is a minimally invasive and simple technique which appears to give satisfactory outcomes in the short to intermediate term

Manifestations and treatment of the hand in adult congenital erythropoietic porphyria

Congenital erythropoietic porphyria (CEP) is a rare enzymatic disorder of heme metabolism, leading to the accumulation of porphyrins in the skin and subdermal structures. We present the case of a 34-year-old, right-hand-dominant, male patient with CEP. The patient had developed a chronic open subluxation of the left index finger proximal interphalangeal joint due to skin necrosis. We successfully treated the patient with proximal interphalangeal arthrodesis. This case demonstrates that childhood-onset CEP can also manifest in the adult hand. Considering the patient's age, the destructive nature of the disease, and the poor quality of function in older patients with childhood CEP, surgical intervention was necessary to avoid further digital length loss. Although the treatment described in this case report is not uncommon, we found it essential to present this case because the clinical presentation of CEP is rare

Patient activation and disability in upper extremity illness

PURPOSE: To determine if higher patient activation (active involvement in one's health care) correlates with fewer symptoms and less disability in patients with hand and upper extremity illness. METHODS: We enrolled 112 patients presenting to our department for the first time. Before meeting with the surgeon, subjects completed a demographics questionnaire, the short form Patient Activation Measure; Quick Disabilities of the Arm, Shoulder, and Hand; Patient Health Questionnaire-2; Pain Self-Efficacy Questionnaire; and an 11-point ordinal rating of pain intensity. We contacted patients 1 to 2 months after enrollment. Seventy-five subjects completed the second evaluation over the telephone, on a secure data-collection web site, or in an office visit, which included the Patient Activation Measure; Quick Disabilities of the Arm, Shoulder, and Hand; numerical rating scale for pain; and ordinal rating of treatment satisfaction. RESULTS: Patient activation at enrollment correlated with disability, pain intensity, and satisfaction with treatment but was only retained in the multivariable model for pain intensity. Pain self-efficacy at enrollment was the factor that best accounted for variation in disability, pain, and satisfaction with treatment. CONCLUSIONS: Given the consistent relationship between effective coping strategies (eg, pain self-efficacy) and symptoms and disability and the independent influence of patient activation on pain intensity in this study, future research should address the ability of interventions that improve self-efficacy and patient activation to improve upper extremity health. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II

Reliability of Diagnosis of Partial Union of Scaphoid Waist Fractures on Computed Tomography

Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the percentage of the fracture gap that is bridged by healing bone. This study tested the primary null hypothesis that there is no agreement between observers on the extent of union of a scaphoid waist fracture on CT. CT scans of 13 nondisplaced scaphoid waist fractures treated nonoperatively were rated by 145 observers. CT scans were done 10 to 12 weeks after injury. Observers were asked to "eyeball" measure percentage of union. We found that there was a moderate agreement on the categorical degree of partial union of a scaphoid waist fracture on CT (kappa = 0.34). Agreement on the location of bony bridging was slight (kappa = 0.31). We concluded that there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT and that this should be taken into account in both patient care and research. This is a Level Ill, diagnostic study

Treatment of Symptomatic Distal Interphalangeal Joint Arthritis with Percutaneous Arthrodesis: a Novel Technique in Select Patients

Arthrodesis of the distal interphalangeal (DIP) joint is a reliable means of achieving pain relief in a symptomatic DIP joint afflicted by a variety of degenerative, inflammatory, or posttraumatic conditions. Successful arthrodesis is more reproducible when rigid compression of the joint is achieved. The emergence of an increasing number of commercially available headless or variable pitch compression screws reflects the growing trend among hand surgeons to utilize rigid stabilization of the DIP joint so that motion at more proximal levels can be initiated immediately without affecting arthrodesis rates. Successful closed percutaneous DIP arthrodesis can be achieved in a patient with hypertrophic osteoarthropathy, passively correctable deformity, and patients at increased risk for perioperative soft tissue complications associated with open arthrodesis. We present a novel percutaneous DIP fusion technique utilizing a cannulated headless compression screw in a select group of patients. The sagittal plane diameters of the distal and middle phalanges are templated. Cannulated headless compression screws, 2.4 and 3.0 mm, with short or long terminal threads at the leading end of the screw are selected based upon patient-specific anatomic considerations. Pain-free status and radiographic fusion were achieved in both patients (gout arthropathy, n = 1; posttraumatic arthritis, n = 1) at an average of 6 weeks postoperatively. Our current indications, along with pearls and pitfalls with this technique, are reviewed. In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques