Aims. The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality. Methods. A multicentre, cross-sectional retrospective study of MSFs at six centres in the UK. We collected and analyzed healthcare records, operative notes, and radiographs of adults presenting within ten days of a MSF affecting the second to fifth metacarpal between 1 August 2016 and 31 July 2017. Total emergency department (ED) attendances were used to estimate prevalence. Results. A total of 793 patients (75% male, 25% female) with 897 MSFs were included, comprising 0.1% of 837,212 ED attendances. The annual incidence of MSF was 40 per 100,000. The median age was 27 years (IQR 21 to 41); the highest incidence was in men aged 16 to 24 years. Transverse fractures were the most common. Over 80% of all fractures were treated non-surgically, with variation across centres. Overall, 12 types of non-surgical and six types of surgical treatment were used. Fracture pattern, complexity, displacement, and age determined choice of treatment. Patients who were treated surgically required more radiographs and longer radiological and outpatient follow-up, and were more likely to be referred for therapy. Complications occurred in 5% of patients (39/793). Most patients attended planned follow-up, with 20% (160/783) failing to attend at least one or more clinic appointments. Conclusion. MSFs are common hand injuries among young, working (economically active) men, but there is considerable heterogeneity in treatment, rehabilitation, and resource use. They are a burden on healthcare resources and society, thus further research is needed to optimize treatment. Cite this article: Bone Jt Open 2024;5(8):652–661

Aims. To determine whether an early return to sport in professional Australian Rules Football players after fixation of a non-thumb metacarpal fracture was safe and effective. Patients and Methods. A total of 16 patients with a mean age of 25 years (19 to 30) identified as having a non-thumb metacarpal fracture underwent open reduction and internal plate and screw fixation. We compared the players’ professional performance statistics before and after the injury to determine whether there was any deterioration in their post-operative performance. Results. Of the 16, 12 sustained their fracture during the season: their mean time to return to unrestricted professional play was two weeks (1 to 5). All except two of the 48 player performance variables showed no reduction in performance post-operatively. Conclusion. Our data suggest that professional athletes who sustained a non-thumb metacarpal fracture can safely return to professional play without restriction two weeks after internal fixation. Cite this article: Bone Joint J 2017;99-B:1343–7

Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures. The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation. 42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes. All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group. The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008). When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment. Trial registration number: ClinicalTrials.gov NCT03067454

Our aim was to explore factors associated with early post operative infection for surgically managed base of 4th/5th metacarpal fractures. We hypothesised that K-wires crossing the 4th and 5th carpometacarpal joint (CMCJ) would be associated with an increased risk of post-operative infection. Data from consecutive patients requiring surgical fixation for a base of 4th/5th metacarpal fracture from October 2016 to May 2021 were collected. Patient demographics, time to surgery, length of surgery, operator experience, use of tourniquet, intra-operative antibiotics, number and thickness of K-wire used, as well as whether or not the K-wires crossed CMCJ joints were recorded. Factors associated with post operative infection were assessed using Chi Squared test and univariable logistic regression using R studio. Of 107 patients, 10 (9.3%) suffered post operative infection. Time to surgery (p 0.006) and length of operation (p=0.005) were higher in those experiencing infection. There was a trend towards higher risk of infection seen in those who had K-wires crossed (p=0.06). On univariable analysis, patients who had wires crossed were >7 times more likely to experience infection than those who didn't (OR 7.79 (95% CI, 1.39 - 146.0, p=0.056). Age, smoking, K-wire size, number of K-wires used, intraoperative antibiotics, tourniquet use and operator experience were not associated with infection. In patients with a base of 4th/5th metacarpal fractures requiring surgical fixation, we find an increased risk of post-operative infection associated with K-wires crossing the CMCJ, which has implications for surgical technique. Larger prospective studies would be useful in further delineating these findings

There is no agreement as to the superiority or specific indications for cast treatment, percutaneous pinning or open fracture fixation for Bennett's fractures of the thumb metacarpal. We undertook this study to compare the outcomes of treatment for patients treated for Bennett's fracture in the medium term. We reviewed 33 patients treated in our unit for a bennett's fracture to the thumb metacarpal with closed reduction and casting. Each patient was matched with a patient treated surgically. Patients were matched for sex, age, Gedda grade of injury and hand dominance. Patients were reviewed at a minimum of 5-years and 66-patients were reviewed in total. Patients were examined clinically and also asked to complete a DASH questionnaire score and the brief Michigan hand questionnaire. Follow up plain radiographs were taken of the thumb and these were reviewed and graded for degenerative change using the Eaton-Littler score. Sixty-six patients were included in the study, with 33 in the surgical and non-surgical cohorts respectively. The average age was 39 years old. In each cohort, 12/33 were female, 19/33 were right-handed with 25% of individuals injuring their dominant hand. In each coort there were 16 Grade 1 fractures, 4 Grade 2 and 13 Grade 3 fractures. There was no difference between the surgically treated and cast-treatment cohorts of patients when radiographic arthritis, pinch grip, the brief Michigan Hand Questionnaire and pain were assessed at final review. The surgical cohort had significantly lower DASH scores at final follow-up. There was no significant difference in the normalised bMHQ scores. Our study was unable to demonstrate superiority of either operative or non-operative fracture stabilization. Patients in the surgical cohort reported superior satisfaction and DASH scores but did not demonstrate any superiority in any other objectively measured domain

Our aim was to ascertain if K-wire configuration had any influence on the infection and complication rate for base of 4th and 5th metacarpal fractures. We hypothesised that in individuals whose wires crossed the 4th and 5th carpometacarpal joint (CMCJ), the rate of complications and infection would be higher. Data was retrospectively analysed from a single centre. 106 consecutive patients with a base of 5th (with or without an associated 4th metacarpal fracture) were analysed between October 2016 and May 2021. Patients were split into two groups for comparison; those who did not have K-wires crossing the CMCJ's and those in whose fixation had wires crossing the joints. Confounding factors were accounted for and Statistical analysis was performed using SPSS version 20 software. Of 106 patients, 60 (56.6%) patients did have K-wires crossing the CMCJ. Wire size ranged from 1.2-2.0 with 65 individuals (65.7%) having size 1.6 wires inserted. The majority of patients, 66 (62.9%) underwent fixation with two wires (range 1-4). The majority of infected cases (88.9%) were in patients who had k-wires crossing the CMCJ, this trended towards clinical significance (p=0.09). Infection was associated with delay to theatre (p=0.002) and longer operative time (p=0.002). In patients with a base of 4th and 5th metacarpal fractures, we have demonstrated an increased risk of post-operative infection with a K-wire configuration that crosses the CMCJ. Biomechanical studies would be of use in determining the exact amount of movement across the CMCJ, with the different K-wire configuration in common use, and this will be part of a follow-up study

Aims. The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires. Patients and Methods. This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications. Results. Overall, 151/290 of patients (52%) completed the six months of follow-up, leaving 83 patients in the single-wire group and 68 patients in the dual-wire group. In the modified intention-to-treat analysis set, mean DASH scores six months after surgery were 3.8 (. sd. 7.0) and 4.4 (. sd. 9.4), respectively. With multiple imputation (n = 288), mean DASH scores were estimated at 6.3 (. sd. 8.7) and 7.0 (. sd. 10.0). Upper (1 - 2α)) confidence limits consistently remained below the noninferiority margin of 3.0 points in the DASH instrument. While there was a statistically nonsignificant trend towards a higher rate of shortening and rotational malalignment in the single wire group, no statistically significant differences were observed across groups in any secondary outcome measure. Conclusion. A single thick K-wire is sufficient for intramedullary fixation of acute displaced subcapital fractures of the fifth metacarpal neck. The less technically demanding single-wire technique produces noninferior clinical and radiological outcomes compared with the dual-wire approach. Cite this article: Bone Joint J 2019;101-B:1263–1271

Abstract. Objectives. 1. To describe the epidemiology of metacarpal shaft fractures (MSF) in adults. 2. To evaluate the variation in practice and document complications following usual care. 3. To explore factors associated with treatment modality. 4. To document hospital resource use following MSF. Methods. A multi-centre, retrospective, cross-sectional study of MSF at six centres. The healthcare records, operative notes and imaging of adults presenting within 10 days of a MSF, affecting the second to fifth metacarpal between 1st August 2016 to 31st July 2017, were reviewed. Total number of Emergency Department (ED) attendances were used to calculate prevalence. Data analyses are primarily descriptive with 95% confidence intervals to quantify uncertainty in estimates. Results. Of 837, 212 ED attendances, 793 patients (75% male, 25% female), with 897 MSF were eligible, a prevalence of 0.1%. The median age was 27 years (16–97); the highest incidence was in males aged between 16 and 24 years. The most common fracture pattern was transverse. While 83% were treated non-surgically overall, this varied across centres. Twelve different types of non-surgical and six different types of surgical treatment were used. Multi-fragmentary fracture patterns were most likely to be treated surgically and long oblique least likely. Fracture pattern, complexity, displacement and age were associated with treatment modality. Patients treated surgically required more radiographs, longer radiographic and outpatient follow-up and were more likely to be referred for therapy. 5% (39/793) experienced a complication. 20% (160/783) failed to attend at least one or more clinic appointments. Conclusions. MSF are a common injuries, predominantly affecting young males of working age. There is variation in mode and type of treatment, with the majority treated non-surgically in the selected centres. Despite a low complication rate, they require considerable secondary care resources. Further research into the optimal treatment modality for these injuries is needed. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. The exact aetiology and pathogenesis of microdamage-induced long bone fractures remain unknown. These fractures are likely to be the result of inadequate bone remodelling in response to damage. This study aims to identify an association of osteocyte apoptosis, the presence of osteocytic osteolysis, and any alterations in sclerostin expression with a fracture of the third metacarpal (Mc-III) bone of Thoroughbred racehorses. Methods. A total of 30 Mc-III bones were obtained; ten bones were fractured during racing, ten were from the contralateral limb, and ten were from control horses. Each Mc-III bone was divided into a fracture site, condyle, condylar groove, and sagittal ridge. Microcracks and diffuse microdamage were quantified. Apoptotic osteocytes were measured using TUNEL staining. Cathepsin K, matrix metalloproteinase-13 (MMP-13), HtrA1, and sclerostin expression were analyzed. Results. In the fracture group, microdamage was elevated 38.9% (. sd 2.6. ) compared with controls. There was no difference in the osteocyte number and the percentage of apoptotic cells between contralateral limb and unraced control; however, there were significantly fewer apoptotic cells in fractured samples (p < 0.02). Immunohistochemistry showed that in deep zones of the fractured samples, sclerostin expression was significantly higher (p < 0.03) than the total number of osteocytes. No increase in cathepsin K, MMP-13, or HtrA1 was present. Conclusion. There is increased microdamage in Mc-III bones that have fractured during racing. In this study, this is not associated with osteocyte apoptosis or osteocytic osteolysis. The finding of increased sclerostin in the region of the fracture suggests that this protein may be playing a key role in the regulation of bone microdamage during stress adaptation. Cite this article: N. Hopper, E. Singer, F. Henson. Increased sclerostin associated with stress fracture of the third metacarpal bone in the Thoroughbred racehorse. Bone Joint Res 2018;7:94–102. DOI: 10.1302/2046-3758.71.BJR-2016-0202.R4

Two case reports illustrate a relatively simple procedure to preserve thumb function in trauma and locally invasive tumours. The first case report is of a man who presented with a slowly growing chondrosarcoma involving his left thumb metacarpal. Radiological investigations and incision biopsy confirmed the diagnosis of a low-grade chondrosarcoma. Thumb function sparing wide local excision of the metacarpal, including the thenar muscles was carried out. The floating thumb was stabilised with a temporary silicone block interposed between trapezium and the proximal phalanx. After four weeks the silicone block was replaced with a tri cortical bone graft from the opposite iliac crest and fixed distally to the proximal phalanx and proximally to the trapezium. The second case report is of a soldier who sustained multiple injuries including open fractures of left thumb metacarpal with associated soft tissue and bone loss. This was from a mortar shell explosion in the jungle. After immediate debridement locally he was transferred to the UK. On arrival he was found to be septic and with ARDS, requiring ITU treatment. One week later he underwent debridement and stabilisation of his thumb injury with an external fixator. This got infected and he went on to develop a non-union. He needed multiple visits to the Operating theatre to sort out his other injuries. Some seven months post trauma he went on to have the metacarpal successfully reconstructed using iliac crest bone graft. These two very different cases underwent a similar reconstructive procedure to try and preserve the thumb and regain some function. After rehabilitation both patients are pleased to have had their thumb preserved

The use of plates and screws for the treatment of certain metacarpal fractures is well established. Securing plates with bicortical screws has been considered an accepted practice. However, no study has questioned this. This study biomechanically assessed the use of bicortical versus unicortical screws in metacarpal plating. Eighteen fresh frozen cadaveric metacarpals were subject to midshaft transverse osteotomies and randomly divided into two groups. Using dorsally applied Leibinger 2.3mm 4 hole plates, one group was secured using 6mm unicortical screws, while the second group had bicortical screws. Metacarpals were tested to failure using a four point bending protocol in an apex dorsal direction on a servo-hydraulic testing machine with a 1kN load cell. Load to failure, rigidity, and mechanism of failure were all assessed. Each group had three samples that did not fail after a 900 N load was applied. Of those that failed, the mean load to failure was 596N and 541 N for the unicortical and bicortical groups respectively. These loads are well in excess of those experienced by the in-vivo metacarpal. The rigidity was 446N/mm and 458N/mm of the uni-cortical and bicortical groups respectively. Fracture at the screw/bone interface was the cause of failure in all that failed, with screw pullout not occurring in any. This study suggests that there may be no biomechanical advantage in using bicortical screws when plating metacarpal fractures. Adopting a unicortical plating method simplifies the operation, and avoids potential complications associated with overdrilling and oversized screws

Introduction: Metacarpal and phalangeal fractures are frequent (13% of the total number of fractures). It seems that the best treatment for the displaced fractures is fixation. Various methods have been used, such as plates and screws, wires, IM-nailing, external fixation. The main problems are adhesions of extensor tendons, scarring and stiffness of the joints. The purpose of this study is to examine the efficacy of internal fixation using Kirschner wires, applied open or closed, treating metacarpal and phalangeal fractures. MATERIALS AND Methods: Between 1998 and 2005 145 out of a total of 2848 (5.2%) metacarpal and phalangeal fractures underwent operative treatment. Fixation was achieved by placing extrarticularly two or more Kirschner wires. The wires were removed after 4 weeks and patients underwent physiotherapy for 2 to 4 weeks. The follow-up period was 3 – 15 mos (average 12 mos) and total range of movement and function of the injured hand was evaluated. Results: Bone union was evident in 3 to 5 weeks. Range of movement was approximately 90% of normal, except for cases of comminuted intraarticular fractures and also in 6 cases of elderly non-cooperative patients. One case of infection, complicating a metacarpal fracture and well responding to antibiotic treatment, was recorded. Three further infections resulted after neglected intraarticular fractures, all of which underwent arthrodesis. No rotational deformities were observed. There was no mechanical failure of the fixation in any case. Conclusion: The fixation of metacarpal and phalangeal fractures using K-wires seems to be a useful method minimally invasive, stable and well tolerated by the patient, not interfering with the mobility of the joints. K-wires are easily removed and of low cost. The functional outcome of this method seems to be quite satisfactory

Introduction. Antegrade K wiring of the fifth metacarpal for treatment of displaced metacarpal neck fractures is a well recognized surgical procedure. However it is not without complication and injury to the dorsal cutaneous branch of the ulnar nerve has been reported in up to 15% of cases. Methods. We performed a cadaver study to determine the proximity of this nerve to the K wire insertion point at the base of the fifth metacarpal. K wires were percutaneously inserted under image intensification in sixteen cadaver hands and advanced into the head of the metacarpal. Wires were then cut and bent outside the skin. This was then followed by meticulous dissection of the ulnar nerve from proximal to distal. A number of measurements were taken to identify the distance from the insertion point of the K wire to each branch of this nerve. Results. The distance from the insertion point at the base of the fifth metacarpal to the dorsal component of the nerve averaged 5.6 mm (range 1mm–12mm) and from the volar component was 6 mm (range 1mm–10mm). The heel of the wire was touching the nerve in five cases. Conclusion. Our findings highlight the importance of making a small incision and bluntly dissecting to bone at the base of the fifth metacarpal to protect the nerve. In addition, use of a tissue protector is vital when drilling the 2mm hole at the base of the fifth metacarpal. We have confirmed that the dorsal cutaneous branch of the ulnar nerve is vulnerable during insertion of an antegrade intramedullary K wire for treatment of neck of fifth metacarpal fractures

Introduction: Intramedullary fixation is a recognised method of fracture fixation in fifth metacarpal fractures. We describe a new technique for fixation of fractures of the middle three metacarpals. Patients and Methods: We reviewed a single surgeon’s series of 16 male patients (mean age 27.9 years, range 18–46) with 20 displaced transverse midshaft fractures of the 2nd, 3rd and 4th metacarpals treated by antegrade intramedullary Kirschner wiring. Work related and domestic accidents constituted the mode of injury in 8 patients and in the remaining 8 as a result of an assault, fall or road traffic accident. Twelve patients were in employment at the time of injury including four heavy manual labourers. A single pre-bent 1.6 millimetre Kirschner wire was inserted into the medullary canal through a drill hole in the metacarpal base and passed across the reduced fracture into the metacarpal head. The proximal end of the wire remained protruding percutaneously. Following stabilisation of the fracture, early mobilisation was commenced. Results: All of the study group had satisfactory clinical and radiological outcomes. All of the fractures united clinically and radiologically. There was one case of delayed union, with union at 35 weeks. In the remaining patients fracture union had occurred radiologically at an average of 5.4 weeks (range 4–12 weeks). Radiologically there was a mean angular deformity of 4.05° (range 0–11°) in the coronal plane and 0.75° (range 0–9°) in the sagittal plane. Postoperatively 2 patients developed a pin tract infection requiring treatment with antibiotics and early removal of the K-wire. All patients on questioning by telephone questionnaire were satisfied with their resulting hand function and appearance. All patients had returned to normal activities of daily living by 8 weeks. Of those patients in employment all had returned to work by 6 weeks (mean 3.3. weeks). Conclusion: Antegrade intramedullary single K wiring is a useful technique for managing unstable midshaft metacarpal fractures producing excellent clinical and radiological results

Two case reports illustrate a relatively simple procedure to preserve thumb function in trauma and locally invasive tumours. The first case report is of a man who presented with a slowly growing chondrosarcoma involving his left thumb metacarpal. Radiological investigations and incision biopsy confirmed the diagnosis of a low-grade chondrosarcoma. Thumb function sparing wide local excision of the metacarpal, including the thenar muscles was carried out. The floating thumb was stabilised with a temporary silicone block interposed between trapezium and the proximal phalanx. After four weeks the silicone block was replaced with a tri cortical bone graft from the opposite iliac crest and fixed distally to the proximal phalanx and proximally to the trapezium. The second case report is of a soldier who sustained multiple injuries including open fracture of left thumb metacarpal with associated soft tissue and bone loss. This was from a mortar shell explosion in a commando operation in the jungle. After immediate debridement locally he was transferred to the UK. On arrival ARDS and sepsis requiring ITU treatment further compromised his clinical status. One week later he underwent debridement and stabilisation of his thumb injury with an external fixature. This got infected and went on to develop a non-union. Some seven months post trauma he went on to have the metacarpal reconstructed using iliac crest bone graft. These two very different cases underwent a similar reconstructive procedure to try and preserve the thumb and regain some function. After rehabilitation both patients are pleased to have their thumb preserved

Locking of the MCP joint of the finger, except with stenosing tenosynovitis, is relatively rare. The middle finger is most frequently involved. We treated 7 patients who had locking of the MCP joint of the middle finger because of osteophyte of the metacarpal head. The locking of the MCP joint usually occurred in the older patient as a result of significant osteophyte around the metacarpal head. Unlocking of the MCP joint was done by closed manipulation under local anaesthesia. Locking of the MCP joint of the finger because of other causes than tenosynovitis has been reported infrequently. Locking of the MCP joint caused by osteophyte of the head of the metacarpal is characterised by painful loss of extension of the MCP joint without loss of flexion. We have treated 7 patients who had locking of the MCP joint occurring in the middle finger with an obvious osteophyte of the metacarpal head. Seven patients, 4 women and 3 men, were treated in our Department. None of the patients had a history of trauma to their hands, and in all of them it was the dominant hand which was affected and usually due to powerful full flexion movement of the fingers. The average age was 73.8 years (65 – 81). The duration of locking was from 3 hours to 14 days. All the patients were treated within 30–60 minutes after reporting to our Clinic. The presentation of the patients was extremely similar. In all cases active and passive extension was blocked and they had pain around the finger. Full flexion was possible. The MCP joint was tender around the palmar aspect with slight diffuse swelling around the dorsal aspect. Radiographs of the MCP showed degenerative changes in all the patients and oblique views demonstrated an osteophyte either on the ulnar or the radial side of the head. Local anaesthetic Lignocaine 1% 5ml was injected in the MCP and around the joint and after 5–10 minutes manipulation was performed, unlocking achieved and the patients straightaway extended and flexed the finger fully. No-one underwent surgical release. Follow-up from 3 to 8 months, average 6 months. No recurrence of the locking. Akio Minami reported 4 cases of MCP joint locking of the middle finger, treated surgically. Williams classified the locking of the MCP joint in 3 groups. Langenskiold reported 2 cases of intrinsic locking of the MCP due to catching of the collateral ligament on the lateral bony projection of the metacarpal head. It is very difficult to explain why the middle finger is most likely affected. Kessler noted that the MCP joint seldom participates in a generalised degenerative OA

In nine patients of median age 34 years who had sustained an amputation of the thumb at a median 24 (5 to 131) months previously, we lengthened the first metacarpal by 30 (17 to 36) mm. Seven amputations had been through the proximal phalanx and two through the metacarpal. The first two patients had autogenous grafting at a second stage, but the other seven had callotasis alone. In these patients the external fixators were removed at a median 189 (115 to 271) days after osteotomy. In six cases the adductor pollicis tendon was transferred proximally and the first web deepened. There was late fracture or palmar flexion of the callus in five patients, but this required further surgery in only one. Treatment was complete at 326 (140 to 489) days after osteotomy. The extended thumb retained its sensitivity; both grasp and key-pinch strength were satisfactory and only one patient felt that the result did not warrant the long course of treatment. Metacarpal lengthening by this method is a prolonged procedure, but provides a valuable alternative to more complex reconstructions

AIM: The purpose of this prospective study was to asses the outcome of antegrade intramedullary wiring of displaced distal end of fifth metacarpal fracture in skeletally immature. Intramedullary wiring for fracture metacarpals have been well described in the literature. Retrograde wiring for neck of metacarpal fractures have been associated with limitation of extension at metacarpo-phalangeal joint due to involvement of gliding extensor mechanism. Foucher described ‘Bouguet’ osteosynthesis with multiple wires for metacarpal neck fracture which can be technically demanding in small bones of children. We describe an antegrade wiring using a single bent K-wire at the tip for reducing and stabilising displaced metacarpal neck fracture by rotating 180 degree after crossing fracture site, a method similar to Methaizeau technique for stabilisation of displaced radial neck fractures using nancy nail. METHOD: Between 2000 to 2006 we treated 9 boys with displaced distal end of fifth metacarpal fracture +/− rotational deformity of little finger using above technique. All of them had closed injuries and the indication for surgery was rotatory mal-alignment or fracture angulation more than 40 degrees. The assessment involved a clinical and radiological examination. The mean age was 13 years. The mean follow-up was 15 months. RESULTS: All fractures healed in anatomical alignment. There was no loss of active or passive movement of the little finger metacarpo-phalangeal joint or weakness of grip strength in any children. All children returned to pre-injury activity level within 4–6 weeks. There were no complications. CONCLUSION: Early results of treating displaced little finger metacarpal neck fracture in children using antegrade intramedullary wire are encouraging

Introduction and Aim: The metacarpal fractures constitute 10% of skeletal fractures in general affecting mainly children and young adults. There is a lot of discrepancy and lack of evidence with regards to correctly managing the little finger metacarpal fractures. Our study was aimed at investigating the current practice of management little finger metacarpal fractures among upper limb surgeons in United Kingdom. Methods: We conducted an online survey between June 2006 and June 2007 consisting of 10 multiple-choice questions that was e-mailed to 278 upper limb orthopaedic specialist surgeons. The response rate was 58% (n = 158) from the upper limb surgeons. Four questionnaires had to be excluded due to multiple responses to each question or incomplete forms. Results: 43% upper limb surgeons prefer neighbour strapping alone for non-operative management of little finger metacarpal fractures. Ulnar gutter cast or splint was the next choice among 19% upper limb surgeons while 13% respondents apply neighbour strapping to ring finger along with a splint. There was mixed response regarding period of immobilisation. 40% of surgeons were in favour of 3 weeks of immobilisation, 23% for 2 weeks while 28% do not immobilise these fractures at all. With regard to considering the most important indication(s) for surgical intervention, rotational deformity was the most common indication (84%), followed by open fracture (70%), intra-articular fracture (44%), associated 4th metacarpal fracture (26%), shortening > 5mm (21%) and volar angulation – (15%). If treated non-operatively, the most preferred period of fracture clinic follow up was one visit at 3 weeks by 40% while 36% thought that no follow up is required once decision is made to treat them conservatively. Conclusion: Isolated undisplaced fractures of little metacarpal are usually managed conservatively using a plethora of methods of immobilisation. The indications for operative intervention are open fracture, rotational deformity, intra-articular fractures and shortening. Many clinical studies have demonstrated that in the conservative care of boxer’s fractures (casting, with or without reduction), between 20 degrees and 70 degrees of dorsal angulation is acceptable. We conclude that contemporary literature provides no evidence as to whether conservative or operative methods of the treatment of these fractures is superior, but rather suggests that they are equally effective. We conclude from our survey that there is no consensus even among the upper limb surgeons with regards to management of little finger metacarpal fractures in United Kingdom

We reviewed our results and complications of using a pre-bent 1.6mm Kirschner wire (K-wire) for extra-articular metacarpal fractures. The surgical procedure was indicated for angulation at the fracture site in a true lateral radiograph of at least 30 degrees and/or in the presence of a rotatory deformity. A single K-wire is pre-bent in a lazy-S fashion with a sharp bend at approximately 5 millimetres and a longer smooth curve bent in the opposite direction. An initial entry point is made at the base of the metacarpal using a 2.5mm drill by hand. The K-wire is inserted blunt end first in an antegrade manner and the fracture reduced as the wire is passed across the fracture site. With the wire acting as three-point fixation, early mobilisation is commenced at the metacarpo-phalangeal joint in a Futuro hand splint. The wire is usually removed with pliers post-operatively at four weeks in the fracture clinic. We studied internal fixation of 18 little finger and 2 ring finger metacarpal fractures from November 2007 to August 2009. The average age of the cohort was 25 years with 3 women and 17 men. The predominant mechanism was a punch injury with 5 diaphyseal and 15 metacarpal neck fractures. The time to surgical intervention was a mean 13 days (range 4 to 28 days). All fractures proceeded to bony union. The wire was extracted at an average of 4.4 weeks (range three to six weeks). At an average follow up of 8 weeks, one fracture had to be revised for failed fixation and three superficial wound infections needed antibiotic treatment. With this simple and minimally invasive technique performed as day-case surgery, all patients were able to start mobilisation immediately. The general outcome was good hand function with few complications

We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Metacarpal osteotomy was equally successful in relieving symptoms of those with early (grade 2) and moderate (grade 3) degenerative changes. This simple procedure provides lasting pain relief, corrects adduction contracture and restores grip and pinch strength, giving good results with few complications

From 1987 to 1993 we treated 33 patients with 29 phalangeal and seven metacarpal fractures by external fixation using a mini-Hoffmann device. There were 27 open and 25 comminuted fractures. In 12 patients one or more tendons was involved. The mean follow-up was 4.4 years. Complications occurred in ten fractures; two required repositioning of the fixator. All the fractures healed. The functional results after metacarpal fractures were better than those after phalangeal fractures and fractures of the middle phalanx had better recovery than those of the proximal phalanx. Twenty-eight of the 33 patients were satisfied with their result. External fixation proved to be a suitable technique for stabilising unstable, open fractures with severe soft-tissue injuries

1. Rotational deformity of a finger caused by malunion of a phalangeal fracture has been corrected by metacarpal osteotomy. 2. Because of the anatomical arrangement of the metacarpo-phalangeal joint this method gives good control of the distal phalanges. 3. Division through the metacarpal rather than through the phalanx avoids adhesions in the flexor and extensor mechanisms and in the joints of the fingers, allows early mobilisation and is an easier procedure

The previous bioabsorbable plates have had several issues with regard to clinical usage for fractures. The aims of this study were to demonstrate the clinical results of novel bioabsorbable plates made of hydroxyapatite/poly-L-lactide and titanium plates for metacarpal fractures and to compare mechanical properties of them in a fracture model. The subjects were 33 metacarpal diaphyseal fractures of 27 consecutive patients treated with bioabsorbable plates. The mean age was 35.8 (17–78), 22 male and 5 female was included. The mean follow up period was 7.4months (2–14). All cases achieved bone union, and there were no complication especially for aseptic swelling etc. Furthermore, we compared the mechanical properties of bioabsorbable and titanium plates. There were no significant differences in 6 month postoperative clinical results including total range of active motion and % of the contralateral grip strength between patients receiving bioabsorbable and titanium plates. The bending strength and stiffness of one-third tubular bioabsorbable plate constructs were comparable with those of titanium plates for 1.5mm screws, and those of semi-tubular bioabsorbable plates were comparable with those of titanium plates for 2.0mm screws. The torsional strength of semi-tubular bioabsorbable plates was significantly greater than that of titanium plates for 2.0mm screws

Introduction: Although a variety of fixation techniques have been reported for fixation of oblique or spiral metacarpal fractures, lag screw fixation has been reported to be the most biomechanically stable method. Lag screws are inserted following over-drilling of the proximal cortex, which provides compression at the fracture site. We believe the compression provided by the Leibinger Bow system makes over-drilling unnecessary. Methods: Twenty fresh-frozen human cadaveric metacarpal bones (index, ring and middle) were utilised. Bones were cleared of soft tissue and the proximal ends were embedded in Wood’s metal using a Teflon mould. Long oblique osteotomies were performed with a fine oscillating saw. Bones were randomly allocated to lagged and non-lagged groups. All bones were held in the Leibinger Bow and fixed with two screws at right-angles across the fracture site. The proximal cortex of the lagged specimens was over-drilled and the non-lagged specimens were not. The bones were subjected to cantilevered bending to failure in a mechanical testing machine. The axial stress was calculated from results for load to failure and the moment of inertia for each specimen. Results: All specimens failed through the proximal screw. Analysis of variance statistical analysis revealed no significant difference in axial stress between the two groups. Conclusions: Minute errors during over-drilling of the proximal cortex can easily lead to inadequate fixation. These data suggest that the use of the Leibinger Bow System may eliminate the need for this over-drilling. This not only shortens the procedure, but also reduces the chance of errors leading to poor fixation

Background. Boxer's fractures are the most common type of metacarpal fracture. It commonly occurs during fistfights or from punching a wall. Greer et al demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self- harm and impulsive behavior, compared with control groups (3). There is little that has been reported on children and adolescents who present with such fractures. This study aims to assess aggression scores in young patients with metacarpal fractures due to punching using a validated questionnaire. Methodology. Following ethical permission, 11–18 year olds, with a boxers fracture and willing to complete an anonymous questionnaire were included. If they were under 16, parental permission was sought. The Buss and Warren validated questionnaire included subscales of physical aggression and anger scales as well as overall aggression scoring. Results. 48 patients who had metacarpal fractures due to punching have completed the study to date. There were 46 males and 2 females. The physical aggression scores ranged from 11–40 with a mean of 25, median 35.5 and mode 14. 24 patients demonstrated high aggression scores. Anger scores ranged from 7–33. Mean 19, mode 13, median 18.5. 18 patients demonstrated high anger scores. Overall aggression scores ranged from 43–148 with a mean of 96 and median of 92.5. Nineteen patients demonstrated high scores. Discussion. This study shows that 40% of the patients had higher overall aggression levels than the normal population. The physical aggression subscale focused on the use of physical force and 50% had high physical aggression levels. High scores in this subscale indicate a lack of ability to control urges toward physical aggression and this is often seen in children with attention deficit disorder. Anger scores may indicate a number of conduct disorders/abusive situations and in this study 38% had raised anger scores. This may be relevant in assessing children with punch injuries as they may benefit from assessment by the CAMS team for investigation and management of their anger and aggression issues, which in turn may reduce recurrence of the injuries

1. A case of actinomycosis of the metacarpal bone of the right little finger from a punch injury is described. 2. The infection lasted five months and responded to prolonged courses of antibiotics and iodine preparations and drainage of recurrent abscesses

1. Three patients with enchondromata of the metacarpal bones are described. 2. The nature of the enchondromata in all three patients was confirmed by histological examination. 3. Treatment was by radical excision and bridging of the gap by a cortical bone graft. 4. There has been no impairment of function in the hands. No patient complained of pain after the operation. 5. Radiographs taken one year after operation in two patients showed that the flat bone grafts had become cylindrical and that medullary canals had appeared

Aim of the study: The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after fracture healing had been completed, in metacarpal fractures treated with third generation bioabsorbable implants. Materials and Methods: 12 unstable, displaced metacarpal fractures in 10 consecutive patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with third generation absorbable plates and screws (Inion. ®. OTPSTM Biodegradable Mini Plating System), where resorption is supposed to occur within 2 to 4 years. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m) and were examined both clinically and radiologically. For patients without appearance of foreign body reaction the minimum follow-up time was 24 months. Results: Fracture healing was uneventful in all cases. A foreign body reaction was observed more than a year postoperatively in 4 patients, who were subjected to surgical debridement and implant remnants removal. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction. 2 further patients reported a self subsiding transient local swelling. Conclusion: Our results indicate that modern absorbable implants with longer degradation period have not eliminated the problem of foreign body reaction, but simply postponed it at a later time postoperatively. Patients treated with bioabsorbable implants should be advised of this possible late complication and should be followed for at least two years, possibly longer

The aim of the study was to assess the outcome of fractures of the fifth metacarpal neck and to develop an accurate method of assessing fracture angulation. Forty-two patients who were available for review were assessed using a patient questionnaire, assessing range of movement, cosmesis, pain and strength. A trigonometric method of determining true fracture angulation from AP and oblique radiographs was developed. There were 36 males and 6 females with an average age of 23.4 years, with a minimum follow up of 12 months. Patients with fractures angulated more than 45 degrees in whom reduction was not performed had a significantly lower score for grip strength and function. 32 patients reported a mild cosmetic deformity. The method of reduction and the method and duration of immobilisation did not correlate with the final outcome. A phantom was constructed that confirmed the accuracy of the method of calculating true fracture angulation from the oblique radiographs. Fractures of the fifth metacarpal neck if not reduced to a true angulation of less than 45 degrees produce an unsatisfactory outcome. A method of assessing true angulation has been developed

The aim of this study was to explore whether adverse reactions would occur during the material’s degradation period even at a later time point after surgery and whether these phenomena were clinically significant and would influence the final outcome. 12 unstable, displaced metacarpal fractures in 10 patients (7 males, 3 females; mean age 36.4 y, range 18–75 y) were treated with the Inion. ®. OTPSTM Biodegradable Mini Plating System. 9 patients (10 fractures) were available for follow-up (mean 25.6 months, range 14 to 44 m). For patients without appearance of foreign body reaction the minimum follow-up time was 24 months. Patients were examined both radiologically to evaluate fracture healing, and clinically by completing the DASH-score and a visual analogue scale for pain assessment. Grip strength, finger strength and range of motion of metacarpo-phalangeal and interphalangeal joints were measured. Fracture healing occurred uneventfully in all patients within six weeks. The most important complication was a foreign body reaction observed in 4 of our patients more than a year postoperatively. All were re-operated and had the materials removed. Histological examination confirmed the diagnosis of aseptic inflammation and foreign body reaction. Although internal fixation of metacarpal fractures by using bioabsorbable implants is a satisfactory alternative fixation method, patients should be advised of this possible late complication and should be followed postoperatively for at least one and a half year, possibly longer

Background. Isolated fractures of the distal fourth or fifth metacarpal bones, known as boxer's fractures (BF), are the most common type of metacarpal fracture. Boxer's fractures received their name from one of their most common causes — punching an object with a closed fist. This injury has been described as “a tolerable fracture in an intolerable patient” (1) It occurs commonly during fistfights or from punching a hard object such as a wall. Greer and William demonstrated that it is usually an intentional injury and these patients were at increased risk for recurrent injury (2). Further work suggested that patients with such injuries had higher features of antisocial, self-defeating personality disorders, self harm and impulsive behaviour, compared with control groups (3). It has been suggested that all patients presenting with such an injury should have psychiatric assessment. The majority of studies in the literature have concentrated on adults and little has been reported on children and adolescents who present with such fractures. This study aims to assess aggression scores in young patients discharged with metacarpal fractures due to punching using a validated questionnaire and this abstract presents the interim analysis. Methodology. Following ethical permissions patients between 11 and 18 years of age, discharged with a metacarpal fracture caused by punching diagnosis codes S622, S623 or S624 and willing to complete an anonymous quetionnairre were included. All patients recieved an information sheet and for young people under 16 parental permission was sought. The Bus and Warren validated questionnaire was completed by post, in person or over the telephone. The questionnaire included subscales of physical aggression and anger scales as well as overall aggression scoring and patients were asked to complete all sections. Results. Twenty one patients who had metacarpal fractures due to punching have. completed the study to date. All were males aged between the age of 11 and 18. The physical aggression scores ranged from 13-39 with a mean of 27.5, median 31 and mode 33. Fifteen patients demonstrated high aggression scores. Six patients demonstrated average scores. Anger scores ranged from 7-31. Median 18.5, mode 13, median 20. Thirteen patients had high anger scores compared with their peers. Eight patients were within the average range. Overall aggression scores ranged from 66-133 with a mean of 100 and median of 100. Eleven patients demonstrated high scores and 5 were in the high average range. Discussion/Conclusions. The initial interim results of this study show that over half the patients had higher overall aggression levels than the normal population. The physical aggression subscale focussed on the use of physical force and 71% had high physical aggression levels. High scores in this subscale indicate a lack of ability to control urges toward physical aggression and this is often seen in children with attention deficit disorder. Anger scores may indicate a number of conduct disorders or abusive situations and in this study 62% had raised anger scores. This may be relevant in assessing children with punch injuries as they may benefit from assessment by the CAMS team for investigation and management of their anger and aggression issues which in turn may reduce recurrence of the injuries

Purpose of the study: Fractures of the metacarpals are common injuries generally observed in young males. Nailing, either with a centromedullary configuration or intermetacarpal construction is generally proposed. The nailing procedure nevertheless has its drawbacks: fracture instability, secondary displacement, pin migration, infection, requirement to remove material, injury to the cutaneous dorsal branch of the ulnar nerve, and most importantly, immobilisation for several weeks which is a major inconvenience for these young active patients. In this context, we wanted to compare two fixation systems: a locked plate versus centromedullary nailing. Material and methods: This was a retrospective comparison of consecutive patients from September 2007 to December 2008. The series included 39 cervical fractures of the fifth metacarpal in 39 patients aged 31 years on average. The first 19 patients were treated with a locked plate (Médartis. ®. ) (group A) and the 20 others with descending centromedullary nailing (group B). In group A, a dorsal approach respecting the dorsal cutaneous branch of the ulnar nerve was used. The technique consisted in insertion of distal locking screws enabling fracture reduction on the plate. No postoperative immobilisation was proposed and rapid mobilisation was encouraged. In group B, classical centromedullary nailing was performed with immobilisation with a short Thomine brace and syndactylisation of the last two fingers. Outcome was based on objective criteria (Jamar. ®. force, joint motion, duration of sick leave) and subjective assessment (DASH, VAS). Results: Mean follow-up was 12 months in group A and 8 months in group B. Depending on the type of fracture, plates with different shapes and lengths were used in group A; a single pin was used in group B (16/10 or 20/10). Secondary displacement was more frequent in group B, but the results in recovered motion were better in group B. The only parameter better in group A was length of sick leave; four patients in group A underwent reoperation to remove the plate and for tenoarthrolysis. In all, the outcomes for cervical fractures of the fifth metatarsal were better in group B. Discussion: Our preliminary results in group A show lesser complications and earlier return to work compared with better motion at last follow-up in group B. Centromedullary nailing remains the better treatment for cervical fractures of the fifth metatarsal. The extra cost of the plates does not appear to be warranted for the treatment of neck fractures of the fifth even though the patient can resume occupational activities earlier

Introduction. Rolando type base of thumb metacarpal fractures are potentially debilitating injuries, which can be difficult to manage because of their inherent instability. Malunion is associated with stiffness, pain and weakness of pinch grip. We aimed to assess the outcome of a simple technique for the treatment of this fracture using the principle of ligamentotaxis, with a static, 2-pin external fixator spanning the trapeziometacarpal joint. We present the results and functional outcomes of this technique. Methods. A consecutive series of 8 patients (7 males, 1 female) with Rolando type intra-articular fractures of the base of the first metacarpal was retrospectively reviewed. All cases were performed by the senior author using a static, 2-pin Mini-Hoffman external fixator. Case notes and radiographs were reviewed, and patients' functional outcome assessed using the Quick Disability of Arm, Shoulder and Hand (Quick DASH) scoring system. Mean age of the group was 32.8 years (range 18.1-52.3 years). Mean follow-up was 2.7 years (range 3.5 months to 6.0 years). Results. The mean delay between injury and surgery was 6.6 days (range 1-11). The mean time to frame removal was 28 days (range 15-41). There were 3 cases of superficial pin site infection all of which were treated satisfactorily with oral antibiotic therapy. Follow-up radiographs did not demonstrate any significant joint incongruity or malunion in any case. The mean Quick DASH score was 8 (range 0-23). Mean scores for the work and sport components were 10 (range 0-25) and 3 (range 0-6) respectively. Conclusion. The results of this study demonstrate that this simple method reliably gives excellent hand and thumb function with minimal impact upon work, sport or recreational activities. We recommend the use of spanning trapeziometacarpal external fixation for intra-articular fractures of the base of the first metacarpal

A bilateral congenital abnormality of the trapezium and first metacarpal is described. The condition may be related to abnormal ossification of the trapezium in accordance with Pfitzner's plan. It is quite distinct from osteoarthritis of the trapezio-metacarpal joints

1. A large proportion of fractures were poorly reduced in this series either because the method used was inadequate or because it was inexpertly applied. At first it was thought that immobilisation in plaster gave adequate fixation but it was impossible to be certain that the reduction was not sometimes lost in the interval between manipulation and the check radiograph taken immediately after plaster had been applied. This suggested that in some cases fixation might be lost early although late redisplacement was not seen. 2. The late subjective results in patients with unreduced fractures were good, but there was some loss of thumb mobility partly due to varus deformity of the metacarpal bone and partly due to incomplete compensation for generalised stiffness in and around the joint. 3. Since loss of movement caused little disability and joint involvement rarely produced symptoms due to osteoarthritis, it seems doubtful whether the use of complex methods of treatment is justifiable. 4. Women seem to be predisposed to painful symptoms at the carpo-metacarpal joint of the thumb whether they occur after fracture or in association with non-traumatic osteoarthritis of the joint

External fixation of the first metacarpal was used in Rolando's fracture to counter the forces that cause shortening and articular incongruity. Satisfactory reduction was achieved and maintained in five patients

We completed a retrospective case study of 66 consecutive isolated closed 5. th. metacarpal neck fractures that presented to our Hospital between September 2009 and March 2010. Their management was established by referring to outpatient letters and A&E notes. The aim of the study was to establish if it would be more efficient and cost effective for these patients to be managed in A&E review clinic without compromising patient care. Of these 66 patients, 56 were males and the mean age was 26 years (12–88 years). Four fractures were not followed up at our Trust, six did not attend their outpatient appointment, one did not require follow up. Of the remaining 55, reviewed at a fracture clinic, all but two were managed conservatively, with 47% requiring one outpatient appointment only. The cost of a new patient Orthopaedic outpatient appointment is £180 with subsequent follow up appointments costing £80 per visit, in contrast to an A&E review clinic appointment at a cost of £60. In view of the small percentage in need of surgical intervention: we highlight the possibility for these patients to be managed solely in the A&E department with a management plan made at the A&E review clinic with an option to refer patients if necessary, and the provision of management guidelines and care quality assurance measures. This, we believe, would maintain care quality for these patients, improve efficiency of fracture clinics and decrease cost. We calculate that even if only all the patients that required one follow up appointment could have been managed by A&E alone then the saving to the local health commissioning body over a six month period from within our trust alone, would have been £3000, which across all trusts providing acute trauma services within the NHS would amount to a substantial saving nationwide

A vascularised bone-graft procedure from the base of the second metacarpal was performed in 14 patients with nonunion of the scaphoid. There were 11 men and three women with a mean age of 22 years. In eight patients, who had dorsiflexed intercalated segment instability (DISI), an open wedge was formed at the site of nonunion, and the vascular pedicle was grafted from the volar side. In the six patients without DISI, transplantation was carried out through the same dorsal skin incision. Complete bony union was obtained in all patients after a mean post-operative period of 10.2 weeks, and DISI was corrected in all affected patients. According to Cooney’s clinical scoring system, the results were excellent in five, good in six, and fair in three patients. Because of its technical simplicity and the limited dissection needed, the procedure should be considered for the primary surgical treatment of patients with nonunion of the scaphoid

Introduction. Surgical treatment is justified in patients with fifth metacarpal shaft fractures with angulation exceeding 30 degrees, as these patients are prone to have shortening, restriction of movements, decreased efficiency of the flexor tendons and poor cosmetic results1,2. The authors describe a new technique where these patients can be treated in the clinic non-surgically. Material and Methods. Twenty-three patients with angulated fractures were prospectively enrolled for the study from Jan 2009 to Dec 2009. After appropriately instructing the patient, an ulnar nerve block was performed at the wrist. Once the nerve block had taken effect, the fracture was manipulated and an ulna gutter 3-point moulded splint was applied in the plaster room. The reduction was then confirmed with an x-ray. The patients were seen at 3 weeks for splint removal and for long-term follow-up at least 6 months later. Results. All the patients had a completely pain-free manipulation and complete reduction was achieved in all the patients. There were no complications related to the technique. Conclusions. In the NHS with pressure on resources, the authors suggest the treatment described above of these fractures in the clinic. It is a safe, cost-effective and easily learnt technique

1. Shin splints in five horses is described as a stress fracture of the second metacarpal bone. 2. The value of this finding in relation to stress fracture of the tibia in man is discussed

Purpose of the study: Lengthening can be proposed for children with congenital or acquired short fingers in order to overcome the length defect and improve function, the aesthetic aspect, or enable installation of a hand prosthesis. Three techniques have been proposed. The purpose of this study was to compare the three techniques in terms of lengthening, achieved, cure index, and complication rate. Material and method: The was a series of 13 lengthening procedures for metacarpals in children with congenital or post-trauma sequelae. Results: The callotasis method was used for seven children. Slow distraction using a mini-external fixator was applied for progressive lengthening without bone graft. Mean lengthening was 13 mm (range 8–21) for mean a mean cure index of 81 d/cm (range 41.7 to 140.9). There was one major complication: fracture with angulation. The two-phase progressive distraction method with graft was used in four children. The distraction using a mini-external fixator was rapid, followed by second phase bone graft. Mean lengthening was 22 mm (range 13–32) with a cur index of 40.8 d/cm (range 32.8 to 46). There was one fracture of a grafted zone. Single-phase extemporaneous lengthening with immediate graft was used for two children. The intraoperative distraction of the osteotomy was followed immediately by insertion of the graft. Mean lengthening was 9 mm for a cure index of 50 d/cm. One patient required tenolysis of the extensor at six months because of adherences at the graft site. Discussion: Our results suggest that the two- phase distraction-graft method enables greater lengthening than the callatasis technique for shorter treatment periods but a the cost of a second operation and donor site morbidity. The extemporaneous lengthening method is less ambitious, achieving lengthening to the order of 10 mm, but with a less aggressive procedure

1. The treatment of Bennett's fracture is reviewed and the relative merits of conservative and operative treatment is considered.

2. A closed method of treatment is described and a series of thirty-one patients so treated is analysed. There were twenty-nine successful results.

3. It is urged that conservative treatment is the method of choice, and that operative measures should be reserved for the occasion when closed methods have failed.

The April 2023 Wrist & Hand Roundup. 360. looks at: MRI-based classification for acute scaphoid injuries: the OxSMART; Deep learning for detection of scaphoid fractures?; Ulnar shortening osteotomy in adolescents; Cost-utility analysis of thumb carpometacarpal resection arthroplasty; Arthritis of the wrist following scaphoid fracture nonunion; Extensor hood injuries in elite boxers; Risk factors for reoperation after flexor tendon repair; Nonoperative versus operative treatment for displaced finger metacarpal shaft fractures

Aims. Although chondrosarcomas (CSs) display true malignant features, including local recurrence (LR) and metastases, their behaviour in the hands and feet is thought to differ from that in other parts of the axial and appendicular skeleton by having a lower metastatic potential. The purpose of this study was to investigate the disease-specific and surgical factors that affect the local and systemic prognosis of CS of the hands and feet. Methods. A multicentre retrospective study was carried out at two tertiary sarcoma centres. A database search identified all patients with a CS treated between January 1995 and January 2018. There were 810 CSs of which 76 (9.4%) were located in the fingers, toes, metacarpals, and metatarsal bones. Results. The median age of the study population was 55 years (36 to 68) with a median follow-up of 52 months (22 to 87) months. Overall, 70% of the tumours were in the hand (n = 54) and 30% in the foot (n = 22). Predictors for LR were margin (p = 0.011), anatomical location (p = 0.017), and method of surgical management (p = 0.003). Anatomical location (p = 0.026), histological grade between 1 and 3 (p = 0.004) or 2 and 3 (p = 0.016), and surgical management (p = 0.001) were significant factors for LR-free survival. Disease-specific survival was affected by histological grade (p < 0.001), but not by LR (p = 0.397). Conclusion. Intralesional curettage of a low-grade CS is associated with an increased risk of LR, but LR does not affect disease-specific survival. Therefore, for low-grade CSs of the hands and feet, surgical management should aim to preserve function. In grade 2 CS, our study did not show any decreased disease-specific survival after recurrence; however, we suggest a more aggressive surgical approach to these tumours to prevent local recurrence, especially in the metacarpal and metatarsal bones. In high-grade tumours, the incidence of progressive disease is high and, therefore, the treatment of the primary tumour should be aggressive where possible, and patients observed closely for the development of metastatic disease. Cite this article: Bone Joint J 2021;103-B(3):562–568

Aims. To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour. Methods. A total of 40 patients suffering from non-rheumatoid wrist arthritis were enrolled in a randomized controlled trial comparing the ReMotion and Motec TWAs. Patient-rated and functional outcomes, radiological changes, blood metal ion levels, migration measured by model-based radiostereometric analysis (RSA), bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA), complications, loosening, and revision rates at two years were compared. Results. Patient-Rated Wrist and Hand Evaluation (PRWHE) scores, abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) scores, and pain improved similarly and significantly in both groups. Wrist motion improved significantly in the Motec group only, and forearm rotation in the ReMotion group only. Cobalt (Co) and chromium (Cr) blood ion levels were significantly higher in the metal-on-metal (MoM) Motec group than in the metal-on-polyethylene (MoP) ReMotion group. Mean total translation was 0.65 mm (95% confidence interval (CI) 0.26 to 1.12) and 0.27 mm (95% CI 0.14 to 0.47) for the ReMotion carpal and radial components, and 0.32 mm (95% CI 0.22 to 0.45) and 0.26 mm (95% CI 0.20 to 0.34) for the Motec metacarpal and radial components, respectively. Apart from dorsal and volar tilts, which were significantly higher for the radial ReMotion than for the Motec component, no significant differences in absolute migration occurred. BMD around the radial components never returned to baseline. Almost one-third of patients required reoperation due to complications. Two ReMotion implants were revised to Motec TWAs due to carpal component loosening, and three Motec MoM articulations were revised to metal-on-polyether ether ketone due to painful synovitis. Conclusion. Both implants provided matched function and were stable at short-term follow-up, but with a high complication rate. This procedure should be restricted to specialist centres undertaking prospective analysis until its role is clarified. Cite this article: Bone Joint J 2022;104-B(10):1132–1141

Abstract. Aim. This study aims to Inter and intra observer reliability compare, use of a standard goniometer (SG) to measure intermetacarpal angle (degrees) vs use of a new technique of using a digital vernier calliper (DVC) (mm) to measure the distance between the first and second metacarpal head. Method. Maximal active abduction and extension of both thumbs was measured in 20 healthy volunteers on two occasions at least one week apart by two assessors. Results. The inter and intra-observer agreement was higher & the variance of the data was lower using the DVC with the new technique than the SG for both thumb abduction and extension. Additionally, the correlation between measurement of extension and abduction was higher using the DVC than the SG. Conclusion. Whilst both tools provide acceptable intra and inter-observer agreement, the new technique using a DVC is consistently better and more reliable than a SG in measuring thumb abduction and extension. The study also supports our hypothesis that the thumb rotates around the second metacarpal head with a consistent radius

Thumb carpometacarpal joint (CMCJ) arthritis is a common and debilitating condition. The mainstay of surgical management is Trapeziectomy. Concerns about possible functional implications of collapse of the metacarpal into the arthroplasty space as well as the potential for scaphometacarpal led to the development of techniques to try and prevent this. The purpose of this study was to investigate if there were any significant differences in the long-term outcomes of patients who participated in a randomized trial of trapeziectomy alone compared with trapeziectomy with ligament reconstruction and tendon interposition (LRTI). Sixty-five patients participated in our original trial, the 1 year findings of which were published in 2007. These patients were invited for a follow-up visit at a mean of 17 years (range 15–20) postoperatively. Twenty-eight patients attended, who had 34 operations, 14 trapeziectomy alone and 20 with LRTI. Patients were asked to complete a visual analogue scale (VAS) for satisfaction with the outcome of their procedure, rated on a scale from 0 (most dissatisfied) to 100 (most satisfied). They also completed the short version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) at their appointment. They underwent a functional assessment with a hand therapist and had a radiograph of the thumb. There were no statistically significant differences between the two groups in terms of satisfaction with surgery or functional outcomes, with most measurements showing minimal or no differences in means between the two groups. There was no difference in the space between the metacarpal and scaphoid on radiograph. Radial abduction was the only parameter that was significantly greater in the patients with simple trapeziectomy (median 79°) compared with trapeziectomy with LRTI (median 71°) (p = 0.04). Even at 17 years there is no significant benefit of LRTI over trapeziectomy alone for thumb carpometacarpal joint osteoarthritis

There is currently no commercially available and clinically successful treatment for scapholunate interosseous ligament rupture, the latter leading to the development of hand-wrist osteoarthritis. We have created a novel biodegradable implant which fixed the dissociated scaphoid and lunate bones and encourages regeneration of the ruptured native ligament. To determine if scaphoid and lunate kinematics in cadaveric specimens were maintained during robotic manipulation, when comparing the native wrist with intact ligament and when the implant was installed. Ten cadaveric experiments were performed with identical conditions, except for implant geometry that was personalised to the anatomy of each cadaveric specimen. Each cadaveric arm was mounted upright in a six degrees of freedom robot using k-wires drilled through the radius, ulna, and metacarpals. Infrared markers were attached to scaphoid, lunate, radius, and 3rd metacarpal. Cadaveric specimens were robotically manipulated through flexion-extension and ulnar-radial deviation by ±40° and ±30°, respectively. The cadaveric scaphoid and lunate kinematics were examined with 1) intact native ligament, 2) severed ligament, 3) and installed implant. Digital wrist models were generated from computed tomography scans and included implant geometry, orientation, and location. Motion data were filtered and aligned relative to neutral wrist in the digital models of each specimen using anatomical landmarks. Implant insertion points in the scaphoid and lunate over time were then calculated using digital models, marker data, and inverse kinematics. Root mean squared distance was compared between severed and implant configurations, relative to intact. Preliminary data from five cadaveric specimens indicate that the implant reduced distance between scaphoid and lunate compared to severed configuration for all but three trials. Preliminary results indicate our novel implant reduced scapho-lunate gap caused by ligament transection. Future analysis will reveal if the implant can achieve wrist kinematics similar to the native intact wrist

The Trauma Triage clinic (TTC) is a Virtual Fracture clinic which permits the direct discharge of simple, isolated fractures from the Emergency Department (ED), with consultant review of the clinical notes and radiographs. This study details the outcomes of patients with such injuries over a four-year period. All TTC records between January 2014 and December 2017 were collated from a prospective database. Fractures of the radial head, little finger metacarpal, fifth metatarsal, toe phalanges and soft tissue mallet finger injuries were included. Application of the direct discharge protocol, and any deviations were noted. All records were then re-assessed at a minimum of three years after TTC triage (mean 4.5 years) to ascertain which injuries re-attended the trauma clinic, reasons for re-attendance, source of referral and any subsequent surgical procedures. 6709 patients with fractures of the radial head (1882), little finger metacarpal (1621), fifth metatarsal (1916), toe phalanges (920) and soft tissue mallet finger injures (370) were identified. 963 (14%) patients were offered in-person review after TTC, of which 45 (0.6%) underwent a surgical intervention. 299 (4%) re-attended after TTC direct discharge at a mean time after injury of 11.9 weeks and 12 (0.2%) underwent surgical intervention. Serious interventions, defined as those in which a surgical procedure may have been avoided if the patient had not undergone direct discharge, occurred in 1 patient (0.01%). Re-intervention after direct discharge of simple injuries of the elbow, hand and foot is low. Unnecessary deviations from protocol offer avenues to optimise consumption of service resources

Introduction and Purpose. Metacarpal fractures constitute approximately one third of all hand fractures. The majority of these fractures are treated by conservative non-surgical methods. The aim of this study is to obtain the appropriate anatomical alignment of the fracture with dynamic metacarpal stabilization splint (DMSS) and to maintain the proper bone anatomy until the union is achieved. In addition, by comparing this method with short arm plaster splint (SAPS) application, it is aimed to evaluate whether patients are superior in terms of comfort, range of motion (ROM) and grip strength. Materials and Methods. In our study, SAPS or DMSS was applied to the patients with 5th metacarpal neck fracture randomly after fracture reduction and followed for 3 months. A total of 119 patients with appropriate criteria were included in the study. Radiological alignment of the fracture and amount of joint movements were evaluated during follow-up. Grip strength was evaluated with Jamar dynamometer. EQ-5D-5L and VAS scores were used for clinical evaluation. Results. 103 patients completed their follow-up. 51 patients were treated with SAPS and 52 patients were treated with DMSS. The mean age of the SAPS was 29.5 (SD ± 9.4; 16–53 years) and the mean age of the DMSS group was 27.8 (SD ± 11.6; 16–63). Pressure sores was seen in 5 patients in the DMSS group, while no pressure sore was seen in the SAPS (p = 0.008). There was no significant difference between the two groups in the VAS scores at all times. There was no significant difference between the mean dorsal cortical angulation (DCA) before the reduction, after the reduction and at the third month follow-ups. There was no statistically significant difference between the length of metacarps at first admittion before reduction, after reduction and at third month follow-ups. When the grip strength of the two groups were compared as a percentage, the grip strength of the patients in the DMSS group was found to be higher at 1st month, 2nd month and 3rd month (p <0.001). When the ROM values of the patients were evaluated, DMSS group had a higher degree of ROM in the first month compared to the SAPS group (p <0.001). No statistically significant difference was detected among groups at third month in the ROM of the IP and MP joints. However, wrist ROM was statistically higher in DMSS group at 3rd month (p <0.05). There was a statistically significant difference between EuroQol scores in favor of DMSA group (p <0.05). Discussion and Conclusion. In stable 5th metacarpal neck fractures, DMSA is as effective as SAPS to maintain bone anatomy. In addition, DMSA can be preferred for fixation plaster splint or circular plaster applications for the prevention of reduction in boxer fractures, with the advantage of having high clinical scores, which is an indication of early acquisition of grip strength, ease of use and patient comfort

The second wave of COVID-19 infections in 2021 resulting from the delta strain had a significantly larger impact on the state of New South Wales, Australia and with it the government implemented harsher restrictions. This retrospective cohort study aims to explore how the increased restrictions affected hand trauma presentations and their treatment. Retrospective analysis was performed on patients who underwent hand surgery from the period of June 23 – August 31 in 2020 and 2021 at a level one trauma centre in Western Sydney. During the second-wave lockdown there was an 18.9% decrease in all hand trauma presentations. Despite widespread restrictions placed on the manufacturing, wholesale, retail and construction industries, there was an insignificant difference in work injuries. Stay-at-home orders and reduced availability of professional tradespersons likely contributed to an increase in DIY injuries. Significant reductions in metacarpal and phalangeal fractures coincided with significantly curtailed sporting seasons. The findings from this study can assist in predicting the case-mix of hand trauma presentations and resource allocation in the setting of future waves of COVID-19 and other infectious diseases

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with the flexor carpi radialis (FCR) tendon is one of the most common procedures for the treatment of thumb carpometacarpal (CMC) arthritis. An alternative method involves trapeziectomy alone (TA). The trapeziectomy with LRTI procedure was developed to theoretically improve biomechanical strength and hand function when compared to TA, which leaves an anatomical void proximal to the first metacarpal. The LRTI procedure takes longer to perform and includes an autologous tendon graft. The goal of this retrospective cohort study was to evaluate the clinical outcomes of trapeziectomy with or without LRTI at a minimum follow-up of 1 year. A total of 43 adult patients who had underwent a total of 58 (TA=36, LRTI=22) surgical procedures for CMC arthritis participated in the study. This single surgeon retrospective cohort study sampled patients who underwent CMC arthroplasty with either TA or LRTI techniques between 2008 and 2020 with a minimum time of 1 year post-operatively. The patients were evaluated subjectively (The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire) and objectively (hand/thumb strength, pre/post-operative hand radiographs). Both the TA and LRTI procedures provided good pain relief, motion, strength, and stability without any severe complications. There was no statistically significant difference in hand or thumb strength between the two groups. Radiography showed that compared to the preoperative status, the trapezial space decreased similarly between the two groups. There was no difference in size of collapse between TA and LRTI post-operatively. The TA procedure had similar outcomes to LRTI and has the advantages of shorter surgical time, less incision length, and lower surgical complexity. TA provided equivalent trapezial space to LRTI after the operation. Future study should investigate these two procedures in a head-to-head comparison rather than longitudinally where both surgeon experience and time since procedure at follow-up may have impacted results

Aim. There are no definitive criteria for the definition of osteomyelitis in the hand and wrist and published case series are small. It remains a relatively uncommon, but difficult to treat problem. We present a series of 30 cases from 2016 to 2021 from a tertiary referral centre. We propose that the principles of thorough surgical debridement, dead space management, skeletal stabilisation and culture driven antibiotic therapy are the key to management of osteomyelitis in the hand and wrist. In addition, we show how these basic principles can be used for both functional and aesthetic impact for the wrist and digits with illustrated cases. Methods. We conducted a retrospective chart review over a 6 year period and recorded the site of the infection, the soft tissue and bony management, whether antibiotic eluting bone filler was used, the isolated bacterial species, the number of surgical procedures undertaken to treat the infection and the success rate for clearing the infection. Results. 17/30 cases had pre-existing metalwork in-situ. There were 19 phalangeal/metacarpal infections and 11 carpal infections. 24 patients had native joint involvement. A drug eluting bone void filler was used in 23/30 cases in order to manage the dead space. In 7/30 cases had polymicrobial organisms isolated, 15/30 had only one organism cultured. The most common organism cultured was Staphylococcus aureus. Complete resolution of osteomyelitis or joint infection was achieved in 29/30 cases with follow up ranging from six months to six years. 2/30 cases required thorough debridement of the distal phalanx; bone void filler provided an aesthetically optimal result to improve fingertip contour whilst managing the dead space. Conclusion. Osteomyelitis of the hand and wrist is optimally managed with thorough surgical debridement, dead space management with a drug eluting bone void filler, skeletal stabilisation and culture directed antibiotic therapy. In addition, the bone void filler provides pulp support and improves the aesthetic contour of fingertips in which distal phalangeal osteomyelitis was successfully treated

Abstract. Background. Benign osteolytic lesions of bone represent a diverse group of pathological and clinical entities. The aim of this study is to highlight the importance of intraoperative endoscopic assessment of intramedullary osteolytic lesions in view of the rate of complications during the postoperative follow up period. Methods. 69 patients (median age 27 years) with benign osteolytic lesion had been prospectively followed up from December 2017 to December 2018 in a university hospital in Cairo, Egypt and in a level-1 trauma center in United Kingdom. All patients had been treated by curettage with the aid of endoscopy through a standard incision and 2 portals. Histological analysis was confirmed from intraoperative samples analysis. All patients had received bone allografts from different donor sites (iliac crest, fibula, olecranon, etc). None of them received chemo or radiotherapy. Results. Most of lesions were enchondroma (n=29), followed by Aneurysmal bone cyst (ABC) (n=16), Fibrodysplasia (n=13), Chondromyxoid fibroma (n=3), simple bone cyst (n= 3), non-ossifying fibroma (n= 3), giant cell tumour (n= 1) and chondromyxoid fibroma (n = 1). Site of lesion varied from metacarpals (n = 29), femur (n= 1), lower leg (n= 31), and upper limb (n=18). Complications happened only in 9 cases (pathological fractures (n=2), infection (n= 1), recurrence (n=3, all aneurysmal bone cyst), residual pain (n= 3, all in tibia). None of cases developed malignant transformation. Conclusion. Endoscopy is recommended in management of benign osteolytic bone lesions; as it aids in better visualization of the hidden lesions that are missed even after doing apparently satisfactory blind curettage. From our study the recurrence rate is 2% compared to the known 12–18% recurrence rate in the blind technique from literature

Aims. The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC. Patients and Methods. A total of 628 patients who had sustained these injuries over a one-year period were identified. There were 337 patients in the pre-TTC group and 289 in the post-TTC group. The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) or Foot and Ankle Disability Index (FADI), EuroQol-5D (EQ-5D), visual analogue scale (VAS) pain score, satisfaction rates, and return to work/sport were assessed six months post-injury. The development of late complications was excluded by an electronic record evaluation at three years post-injury. A cost analysis was performed. Results. Outcomes were as good or better post-TTC, compared with pre-TTC scores. At three years, the pre-TTC group required a total of 496 fracture clinic appointments compared with 61 in the post-TTC group. Mean cost per patient was nearly fourfold less after the commencement of the TTC. Conclusion. Management of minor fractures through the Edinburgh TTC results in clinical outcomes that are comparable with the previous system of routine face-to-face consultation. Outpatient workload for these injures was reduced by 88%. Cite this article: Bone Joint J 2018;100-B:959–65

Background: The occurrence of congenitally short metatarsals is associated with an abnormal gait and an aesthetically displeasing appearance. Similarly, short metacarpals result in severe cosmetic disfigurement, particularly in young female patients. Methods: We examined and performed bone lengthening surgery in 13 female and 2 male patients. Of these, procedures were conducted on 12 metatarsals of 8 patients, 4 metacarpals and 1 metatarsal of a single patient, 1 metacarpal and 1 metatarsal of a single patient and 7 metacarpals of 5 patients. The mean age of the patients who underwent metacarpal procedures was 14.5 (10–21) years while the mean age of those who underwent metatarsal procedures was 17.5 (10–25) years. The callotasis method was employed for these procedures and we used either a unilateral external fixator and/or a circular external fixator. Results: The mean healing index and increase in metacarpal length was 1.6 (1.1–2.3) months/cm and 17.6 (13–26) mm, respectively. The mean follow-up period for patients who underwent metacarpal lengthening was 57.5 (12–96) months. The mean healing index and increase in metatarsal length was 1.6 (1.0–2.0) months/cm and 24.3 (20–30) mm respectively. The mean follow-up period for patients who underwent metatarsal lengthening was 48.3 (12–72) months. The preoperative AOFAS (American Orthopaedic Foot and Ankle Society) scores were good in 5 and excellent in 9 cases. The functional scores of metatarso-phalangial (MTP) joint of lengthened metatarsals for the lesser toe were excellent in 12 and good in 2 cases based on the AOFAS scoring system. All patients who underwent metacarpal lengthening reported that they were satisfied and could conduct their daily activities with good functional and aesthetic results. Complications included 4 angulations, 1 subluxation and 1 non-union and were seen in 6 of the metatarsal lengthening cases that exceeded 40% (or > 20 mm) of the total length of the original bone. Interpretation: There are recommendations in the literature that allow for the avoidance of severe complications and for the shortening of the consolidation period. We conclude that the periosteum must be protected with percutaneus osteotomy and lengthening should be performed at a rate of 0.25 mm twice a day, should not exceeding 40% of the original bone length (or > 20 mm). If the anticipated lengthening exceeds these predefined values then we suggest that the procedure should be performed using a circular external fixator with temporary fixation of the MCP or the MTP joint and the inclusion of the proximal phalanx in the frame

Aseptic loosening of the total TMC joint prosthesis occurs frequently and may depend on the design of the prosthesis. Numerous TMC prosthesis designs are available, and new designs are being developed and tested. One of the problems in the clinical studies of TMC prostheses is identifying and predicting prosthetic loosening at an early stage. Roentgen Stereophotogrammetric Analysis (RSA). allows assessment of three-dimensional micromotion of orthopaedic implants with high accuracy. Early micromotion (in the first two postoperative years) of most prostheses is strongly correlated with the development of aseptic loosening. We studied if RSA assessment was possible after total TMC joint arthroplasty. In five cadaveric hands the TMC joint was replaced by the SR-TMC prosthesis. Tantalum beads of 0.8 mm were implanted in the trapezium and first metacarpal bone without extending the standard surgical exposure. The metacarpal prosthesis component was provided with 0.5 mm beads. A three-dimensional surface model of the trapezium component of the SR-TMC prosthesis was prepared to facilitate model-based RSA. After the surgical procedure, RSA radiographs were made of all hands in two commonly used positions for imaging of the TMC joint. The number of visually detected markers for each bone/implant was recorded. Of one cadaver hand, RSA radiographs were made in ten different positions to calculate the measurement error of the performed technique. For the metacarpal bone, all beads were visible in all positions and both (L+R) RSA radiographs. For beads in the polyethylene metacarpal prosthesis component three beads seem sufficient, however in exceptional cases the most proximal placed bead might be invisible due to overprojection by the metal trapezium prosthesis component. Therefore the X-rays should be carefully checked at the radiology department before the patient leaves the ward. Alternatively, an extra bead can be placed in the prosthesis, although this is a lesser option due to possible weakening of the component caused by the placement of the beads. The use of different sizes of beads (0.5/0.8 mm) in the metacarpal bone and metacarpal prosthesis made the interpretation for the analyser easier. The accuracy analysis is currently carried out. First results of these measurements are promising and placement of tantalum beads for RSA analysis during TMC-joint replacement seems feasible

Aims. We report the use of the distal radius and ulna (DRU) classification for the prediction of peak growth (PG) and growth cessation (GC) in 777 patients with idiopathic scoliosis. We compare this classification with other commonly used parameters of maturity. Patients and Methods. The following data were extracted from the patients’ records and radiographs: chronological age, body height (BH), arm span (AS), date of menarche, Risser sign, DRU grade and status of the phalangeal and metacarpal physes. The mean rates of growth were recorded according to each parameter of maturity. PG was defined as the summit of the curve and GC as the plateau in deceleration of growth. The rates of growth at PG and GC were used for analysis using receiver operating characteristic (ROC) curves to determine the strength and cutoff values of the parameters of growth. Results. The most specific grades for PG using the DRU classification were radial grade 6 and ulnar grade 5, and for GC were radial grade 9 and ulnar grade 7. The DRU classification spanned both PG and GC, enabling better prediction of these clinically relevant stages than other methods. The rate of PG (≥ 0.7 cm/month) and GC (≤ 0.15 cm/month) was the same for girls and boys, in BH and AS measurements. Conclusion. This is the first study to note that the DRU classification can predict both PG and GC, providing evidence that it may aid the management of patients with idiopathic scoliosis. Cite this article: Bone Joint J 2016;98-B:1689–96

Introduction. The trapezio-metacarpal joint (TMCJ) is subject to constant multiplanar forces and is stabilised by the bony anatomy and ligamentous structures. Ligament reconstruction can correct the hypermobility and potentially prevent osteoarthritis. Eaton and Littler proposed a surgical technique to reconstruct the volar ligamentous support of this joint. In our cadaveric biomechanical study, we aimed to evaluate the resultant effect of this technique on the mobility of the thumb metacarpal. Materials and method. Seventeen cadaveric hands were prepared and placed on a custom-made jig. Movements at the trapeziometacarpal joint were created using weights. Static digital photographs were taken with intact anterior oblique (AOL) and ulnar collateral ligaments(UCL) and compared with those taken after sectioning these ligaments and following Eaton-Littler reconstructive technique. The photographic records were analyzed using Scion. Image™. Paired T-test was used to establish statistical significance with a p<0.05. Results. AOL and UCL stabilised the TMCJ in extension. Division of these ligaments produced a significant degree of subluxation of the metacarpal at this joint with the thumb in a neutral position. Reconstruction of the ligamentous supports, using the Eaton-Littler technique, reduced the degree of extension. Conclusion. The primary stabilising ligament of the TMCJ is a subject of debate. Our study objectively evaluates the effect of reconstruction of AOL and UCL on various movements at the TMCJ comparing with sectioned and unsectioned specimens. It confirms the role AOL and UCL in resisting extension and utility of the Eaton-Littler procedure in decreasing hyperextension at this joint. This may have clinical utility in traumatic injury and degenerative laxity, by reducing pain and potentially slowing or even preventing the progression of osteoarthritis

The February 2015 Wrist & Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures

1. Sections were cut from the third metacarpal, the radius, the femur and the third lumbar vertebra of thirty-four male and twenty-one female cadavera. The mineral content of these different specimens was measured by ashing and the relationships between the quantity of bone mineral present at these sites were examined. 2. In the females the whole bone density and mineral/unit length at both the midshaft metacarpal and the midshaft radius correlated significantly with the whole bone density at all the other sites. 3. In the males these correlations were much less significant and no significant correlation was found between the whole bone density of either the metacarpal midshaft or the radial midshaft and that of the third lumbar vertebra or the distal femur, although a highly significant correlation was found between those of the distal femur and the lumbar vertebra. 4. It is suggested that in women, measurements of either mineral/unit length or whole bone density of both the midshaft metacarpal and radius provide useful information on the whole bone densities at other sites throughout the skeleton. This work was supported by the Scottish Hospital Endowments Research Trust, the National Fund for Research into Crippling Diseases and G. D. Searle and Co. Ltd., High Wycombe

The dorsal interosseous muscle (DIM) may be indicated in the coverage of small defects of the hand as a proximally or distally based muscle flap. The objective of his two-part study was to define the vascular supply of the interosseous muscles of the hand, and to identify the dominant arterial pedicle of each muscle for potential use of these muscles as muscle or musculocutaneous flaps. A radio-opaque injectate (lead oxide, gelatin and water mixture) was injected into the femoral artery of 10 fresh cadavers. The intrinsic muscles of the hand were meticulously dissected along with their vascular pedicles, removed and radiographed. The number, type, diameter of vascular pedicles of muscles and their distribution were analyzed. The area of the vascular territory supplied by each source vessel was calculated. Ten embalmed cadavers were injected with red latex into their axillary arteries and a similar dissection protocol was followed. Vascularisation of the interosseous muscles is by palmar metacarpal arteries of the deep palmar arterial arch and dorsal metacarpal arteries. In addition to these constant axial blood supplies, there are rich perimuscular plexus from adjacent nutrient arteries. The origins and insertions of the muscles are also supplied by very fine vessels from this plexus. The diameters of the dominant branches ranged from 0.6 to 1.4 mm (mean 1.0 mm). The vascular territories of the dorsal metacarpal and common palmar arteries extend along the medial and lateral parts of the dorsal interosseous muscles. The dorsal interosseous muscle or musculocutaneous flap are more useful than other intrinsic muscles of the hand because the DIM are easily accessible via the dorsal hand and can be split distally or proximally, and a split musculosseous flap based proximally or distally on the dorsal metacarpal artery can be performed. The functional defect in the donor site after an interosseous muscle flap transfer of the second and third interosseous space is tolerable. This anatomic study provides further information to help design various flaps from the hand for local transfer. The authors describe a thirty-two-year-old male patient in whom the third dorsal interosseous muscle was used as a distally based myocutaneous flap to reconstruct a defect in the hand

Tuberculosis of short tubular bones is uncommon after childhood. “Spina Ventosa” is considered the classical radiological presentation and hallmark of this disease. The short tubular bones are uncommon loci for the manifestation of adult skeletal TB. We report our experience with 31 cases of tuberculosis of hand (excluding wrist) with the intention to call attention to its occurrence in infrequently documented areas, to stress upon its morphologic variability and to illustrate little emphasized radiological signs. Material & Methods: (n=31) Age range 1–68 years; M:F – 11:20; duration of symptoms-3 weeks to 2 years; history of Incision and Drainage before presentation −12 (38%) cases; Epitrochlear lymph node enlargement seen in 22 (71%) cases. Radiologically-classical spina ventosa seen in 5 cases; primarily diaphyseal involvement of metacarpal in 9, lesion in metacarpal head in 4, juxtraarticular metacarpal head erosion in 3, metacarpal base lesion in 3, phalangeal involvement in 2, carpometacarpal joint involvement in 2 and primarily small joint involvement in 3 cases. Majority of them were treated conservatively. Follow up is 1–5 years. Discussion: Tuberculosis of hand might mimic several other inflammatory or neoplastic diseases. Disease might be initially painless and constitutional symptoms may be absent. Rapid collection because of lax skin on the dorsum of hand might tempt the surgeon for incision and drainage. FNAC of Epitrochlear lymph nodes may be diagnostic which may be enlarged in 60–70% cases. The clinicoradiological presentation, differential diagnosis and treatment with special reference to dynamic finger traction will be discussed

Introduction. An understanding of anatomic variability can help guide the surgeon on intervention strategies. Well-functioning thumb metacarpophalangeal joints (MCPJ) are essential for carrying out typical daily activities. However, current options for arthroplasty are limited. This is further hindered by the lack of a precise understanding of the geometric variation present in the population. In this paper, we offer new insight into the major modes of geometric variation in the thumb MCP using Statistical Shape Modelling. Methods. Ten participants free from hand or wrist disease or injury were recruited for CT imaging (Ethics Ref:14/LO/1059). 1. Participants were sex matched with mean age 31yrs (range 27–37yrs). Metacarpal (MC1) and proximal phalanx (PP1) bone surfaces were identified in the CT volumes using a greyscale threshold, and meshed. The ten MC1 and ten PP1 segmented bones were aligned by estimating their principal axes using Principal Component Analysis (PCA), and registration was performed to enable statistical comparison of the position of each mesh vertex. PCA was then used again, to reduce the dimensionality of the data by identifying the main ‘modes’ of independent size and shape variation (principal components, PCs) present in the population. Once the PCs were identified, the variation described by each PC was explored by inspecting the shape change at two standard deviations either side of the mean bone shape. Results. For the ten MC1s, over 80% of the variation was described by the first two PCs (Table 1). Figure 1 shows the effect of the variation in PC1. The majority of geometric variation of the ten PP1s was also described by the first two PCs, with PC1 describing 78.9%. Figure 2 shows the effect of this component on the mean bone geometry. Both the distal articulating surface (head) of the MC1 and the proximal articulating surface (base) of the PP1 vary in overall size. However, the MC1 head also varies in shape (curvature), whereas the PP1 base does not appear to undergo noticeable variation in shape. In this study population, smaller MC1 was observed to correlate with a flatter head, whereas the PP1 head shape did not vary with size. Discussion. The flatter MC1 head (smaller height-radius ratio) may have implications for MCPJ instability, and possibly for osteoarthritic degeneration. A recent study predicted similar trends for the first CMC joint. 2. Previous investigation also observed correlation between MC1 head curvature and MCPJ RoM. 3. , which may explain clinical observations of differing thumb movement strategies. This study used a convenience sample and cannot describe a full population's variability, though the high variance captured by only two PCs suggests adequate external validity amongst similar populations. Further confidence would be gained from studying the joint (i.e. single PCA containing both bones), and wider populations. Significance. These data: provide more precise description of anatomic variation; may offer insights into thumb movement strategies and MCPJ osteoarthritic degeneration. 4. ; and support implant design for individuals whose anatomy can bear an anatomic reconstruction. For any figures or tables, please contact the authors directly

Background: Total wrist arthrodesis is a reliable procedure for severely deteriorated and unstable rheumatoid wrist. In 1999, we developed a new wrist fusion rod (WFR), a cannulated titanium rod could be buried into the third metacarpal with proximal fins and a transverse pin to prevent the rod migration and rotation in the medullary canal. After bone preparation, the 4 mm diameter rod was inserted through a guide pin in ante-grade fashion from the carpus to the neck of the third metacarpal to prevent metacarpal fracture. Then the rod was inserted in retrograde fashion into the radius with an introducer, and countersunk until the distal end of the reached the metacarpal isthmus. After burying the rod, it was bent to the desired angle using a special bender. Materials and Methods: Total wrist arthrodesis was performed using this rod on 39 wrists in 33 patients with rheumatoid arthritis (6 males and 27 females). Their radiographic change was Larsen grade IV or V with subluxation at the radiocarpal joint. The mean age at the operation was 60 yrs. old (28 to 75), and the mean duration of the disease was 12 yrs. (3 to 40). The mean follow-up period was 39 mos. (5 to 75). Supplemental fixation with staples was incorporated in this intramedullary fixation. Iliac bone was grafted on 8 mutilated wrists in 8 patients. Postoperative immobilization using a short arm cast or a wrist brace was continued for 8 weeks. Results: Preoperative pain and swelling disappeared in all operated wrists, and grip strength increased in 31 wrists (79%). The mean preoperative grip strength increased from 97 mmHg to 124 mmHg postoperatively. Subluxated wrist was reduced and fused in slight extension and slight ulnar deviation. The rod did not migrate distally or proximally in the medullary canal. Bony fusion was obtained in 36 wrists (92%). Four rods (10%) were broken due to an overuse or a fall before completion of fusion; however, they did not cause any pain. There were no major complications. Conclusion: Using this WFR, rigid fixation at the desired angle was obtained in the total wrist arthrodesis on rheumatoid wrist. It is technically simple, safe and fast to use

Since the 1970s Swanson implant arthroplasty has become a treatment of choice in metacarpohalangeal (MCP) joint arthroplasty in destructed MCP joints of rheumatoid patients. Sutter (Avanta) implant is also composed of silicone but the centre of rotation is more anatomical, and volar to improve extension moment. Clinical results about these implants have been similar but fracture rates of Sutter implant have been reported to be high. Reason for osteolysis is inflammation reaction to silicone particles released from prostheses due to movement of prosthesis in bone or implant fractures. Reports about osteolysis around Swanson implants present variable result. There is not grading of osteolysis in the literature before and we created a new radiographic grading for osteolysis around silicone MCP implants. Grading is based on involvement of cortical bone: Grade I: Osteolysis varying from a single clear line adjacent to the stem of the prosthesis to a larger, clear area which did not involve the bone cortex; Grade II: Osteolysis affecting the bone cortex to a maximum of one half of the thickness of the cortex; Grade III: Osteolysis affecting the cortex to more than one half of its thickness but not perforating the cortex; Grade IV: Osteolysis perforating the cortex. In this study we compare the incidence of radiographic osteolysis following insertion of 89 Swanson and 126 Sutter MCP implants in rheumatoid arthritis patients. Before surgery hands were randomised one by one to Swanson and Sutter implant groups. The mean follow-up time in the two groups of patients was 57 (40–80) and 55 (36–79) months, respectively. A total of 45 (60%) metacarpal and 40 (53%) proximal phalangeal bones showed no osteolytic changes in the Swanson group. In the Sutter group numbers were 20 (21%) and 26 (27%). In the Swanson group, there was less cortical osteolysis and there were 4 (5%) perforations of a metacarpal and no perforations of a proximal phalanx. In the Sutter group, there were 9 (9%) perforations in a metacarpal and 5 (5%) in a proximal phalanx. (p< 0.001). To create a single independent observation of osteolysis for a hand, the worst osteolysis of a metacarpal or proximal phalanx was recorded. There was only one (5%) perforation in the Swanson group, while there were 8 (30%) perforations in the Sutter group (p=0.011). In all grades of our classification, osteolysis was more frequent in the Sutter than in the Swanson group

Background. The trapeziometacorpal joint (TMJ) of the thumb is a common site of primary osteoarthritis. Pain, crepitis and instability secondary to subluxation are common symptoms associated with TMJ arthritis. Conservative therapy help to control symptoms however with time, many patients progress with pain, deformity and functional limitation. The goals of operative intervention are to restore stability and strength, decrease pain and to provide a functional range of motion. Francobal-prosthesis may fulfil these criterions. Technique. We implanted the prosthesis through a dorso-radial straight longitudinal or slightly curved skin incision. A dorsal capsulotomy is performed and at this step adduction deformity should be addressed. An osteotomy of the proximal surface of the first metacarpal is made perpendicular to the long axis of the medullary cavity followed by reaming of the medullary cavity and then a trial fit. This is followed by preparation of the trapezium including removing any osteophytes, drilling of a cavity. Dental burs may be used at this step to deepen the cavity. The process of cementation started by cementation of the cup with its opening neutral to the joint surface, and if there is any muscle tension, bone is removed from the metacarpal before the metacarpal component is cemented. Reduction is achieved by snapping. The capsule and wound are closed and the thumb is immobilised in an adduction splint for ten days. Results. Results showed marked improvement of pain in many patients with high rate of satisfaction. No restriction of movement or instability was observed. In some cases, loosening of the shaft was noticed. However, this does not affect the overall function. Discussion. De La Caffini`re-prosthesis presents one of the operative options in the management of trapeziometacorpal joint (TMJ). Arthritis, however, this operation is recommended only in selective cases where skaphoid-trapezium-trapezoid (STT) joints are not involved

The scaphotrapeziotrapezoid (STT) joint is one of the key link joints between the proximal and the distal carpal rows. We assessed the relationship between the scaphotrapezium (STm) andscaphotrapezoid (STd) joints using computerised tomographyand hypothesised the ratio of STm is =/< STd joint due to which, the possibility of failure of trapeziectomy due to metacarpal collapse is insignificant. We reviewed CT scans of wrist joints of 113 eligible patientsfrom our wrist database between 2009 and 2014 for our study. 31 patients were randomised for interobserver correlation. Reformatted multi-planar sequences were analysed. The ratio of theSTm: STdin sagittal and coronal measurementswas evaluated. Interobserver variations were assessed using the Pearson coefficient. The sex distribution included 68 males and 29 females, 49 left and 64 right wrists. The STm area was larger in 86 (76%) as compared to STd in 27(24%). Average trapezium to trapezoid ratio was 1:1.5. Ratio of area of trapezium: trapezoid joint is 0.30. The anatomic ratio of the STm in the coronal and sagittal planesis 0.3 and that of the STd joint is 0.2. Ratio of the STm: STd in the coronal plane is 0.29. Pearson's coefficient > 0.8. A small subset of patients undergoing trapeziectomy alonefor stage II- IV carpometacarpal arthritis of the thumb are at risk of impingement of the first metacarpal due to collapse. Our assessment of the anatomical relationship of the STT joint with CT scan proves that although the area the STm joint is generally larger than the STd joint, there is no significant correlation on the whole

Trapeziometacarpal arthritis is a common condition, causing symptoms in up to ten percent of women and one percent of men¹. LRTI is the most commonly used surgical technique for this condition however, long-term studies have shown persistent weakness of pinch strength² after surgery. The Ascension® PyroDisk is a pyrocarbon disk shaped implant designed to articulate against the trapezium and metacarpal, preserving the height of the articulation. The objective of this study was to determine whether treatment with a pyrocarbon implant resulted in comparable pain relief and range of motion, whilst providing superior gains in pinch strength when compared to LRTI. This is a prospective randomized control trial comparing pyrocarbon implant to LRTI. Surgeries were accomplished by a single surgeon in a standardized fashion. Patients were evaluated at six weeks, three, six and 12 months following surgery. Data on pain (VAS), function (Patient Rated Wrist Evaluation (PRWE)), mobility and strength (grip, key and lateral pinch) were obtained as well as radiographic assessment of the height of the arthroplasty space. A total of 80 patients had surgery between July 2008 and November 2016. Forty patients were allocated to the PyroDisk group and 40 to the LRTI group. Seventy-four patients (92,5%) completed the one year follow-up. Mean age was slightly older in the PyroDisk group (64 vs 60,8 y.o., p=0,03). Surgical and tourniquet times were longer in the PyroDisk group. There was no difference between the groups in strength, pain or functional outcome at one year. However, VAS was significantly higher in the PyroDisk group at three and six months (4,5 vs 2,4, p < 0,001, 2,6 vs 1,7, p=0,02) and PRWE was also significantly better at three months in the LRTI group (53,7 vs 71,2, p=0,02). The overall complication rate was three times higher in the PyroDisk group (10% vs 30%). Treatment of trapeziometacarpal arthritis with PyroDisk does not provide superior functional gains when compared to LRTI. On the contrary, it seems to result in more pain in the first few months following surgery. This difference in pain is not seen at 1 year after surgery. This may suggest that there is a period of adaptation to the Pyrodisk after its insertion. We also found a higher risk of complications with the use of the PyroDisk

Bone has a number of different functions in the skeleton including the physical roles of support, protection and sound wave conduction. The mechanical properties, required for these different functions varies and can be achieved by compositional adaption of the bone material, in addition to changes in shape and architecture. A number of previous studies have demonstrated the relationship between mechanical function and mineral to collagen ratio in bones from different species. The aim of this study is to test the hypothesis that the mineral to collagen ratio is higher in bone with a mechanically harder matrix within a species. The red deer (Cervus elaphus) (n=6) was chosen as a model for studying bone with extreme properties. The mechanical properties of the antler, metacarpal bone and tympanic bulla were defined by indentation using a bench-top indentation platform (Biodent). The mineral to collagen ratio was quantified using Raman spectroscopy. The deposition of mineral was studied at macro-level using pQCT. The results showed that the hardness (Indentation Distance Increase) was lowest in the metacarpal (8.5µm), followed by the bulla bone (9.4µm) and highest in the antler (14.5µm). Raman spectroscopy showed a mineral:collagen ratio of 1:0.10 (bulla), 1:0.13 (metacarpal) and 1:0.15 (antler) for the different bones. This does not follow the more linear trend previously shown between young's modulus and the mineral:collagen ratio. The location of the mineral appeared to differ between bone types with pQCT revealing locations of concentrated density and banding patterns in antler. Interestingly, Raman spectra showed differences in the amide peaks revealing differences in protein structure. The results reject the hypothesis but also suggest that the organisation of mineral and collagen has an impact on the hardness modulus. We demonstrate that the red deer provides a good model for studying bone specialisation. This work will provide the basis for further investigation into collagen as a controlling factor in mineral deposition

The June 2012 Wrist & Hand Roundup. 360. looks at; radial osteotomy and advanced Kienböck's disease; fixing the Bennett fracture; PEEK plates and four-corner arthrodesis,;carpal tunnel release and haemodialysis; degloved digits and the reverse radial forearm flap; occupational hand injuries; trapeziometacarpal osteoarthritis; fixing the fractured metacarpal neck and pyrocarbon implants for the destroyed PIPJ

Purpose: Trapezium excision and arthroplasty combined with ligament reconstruction as a treatment for first carpometacarpal joint arthritis is known to be associated with synovitis, prosthesis subluxation /dislocation and proximal migration of the metacarpal. To determine the effectiveness of our technique we used the objective and subjective outcome scores to assess the long term results. Methods: Ten patients (11 thumbs) underwent trapezium arthroplasty and ligament reconstruction procedure for grade III/ IV Eaton and Glickel arthritis. The FCR tendon was harvested split into half from proximal to its insertion site. The insertion site was left intact, the split tendon was passed through the first metacarpal base, passed along the radial side of the implant, through scaphoid and back to the 1st metacarpal as an entrapment technique. 7 female and 3 male patients with mean age of 53.9 comprised our series. Off the 10 patients 60% had surgery on their dominant hands. Results: All the patients had excellent results at a mean follow up of 33.5 months. The mean score (Buck-Gramco) for the tip pinch, grip strength and subjective score for pain, function and dexterity was comparable to the contra-lateral side. The mean tarpezial space ratio calculated from plain x-rays at the follow up was 0.37cm (p< 0.01)|There was evidence of synovitis, prosthesis subluxation or shortening of the thumb. Conclusions: This new method of securing the prosthesis does offer excellent results with good patient satisfaction

Introduction and Aims: Many surgical techniques are available for thumb reconstruction. These include deepening of the first web, flaps, osteoplastic reconstructions, toe to thumb transfer, pollicisation and metacarpal lengthening. The aim of this study is to assess the outcome following use of distraction methods for thumb lengthening. Method: Nineteen patients who underwent thumb metacarpal lengthening over a six-year period have been reviewed retrospectively. Lengthening was performed for terminal deficiency in 12 cases and for segmental bone loss in seven cases. The callotasis method was used in 11 patients and the Matev method in eight. The Orthofix mini-external fixator was used as the distracting device in all cases. Results: Final gains in length achieved measured from 22mm to 41mm, with an average fixator application time of 86 days (range 58 to 125). Complications included two malunions, one overlengthening, four pin migrations through bone and six cases of pin track sepsis. There were no skin or neurovascular complications. Narrowing of the first web space has been found to be a significant problem associated with thumb metacarpal lengthening in this study. This necessitated subsequent deepening of the web space in 14 patients with adductor release in seven patients. Conclusion: Distraction methods for thumb reconstruction are relatively easy, safe and do not require special facilities or prolonged theatre time. Where indicated, these techniques provide a useful alternative to other methods of thumb reconstruction

Purpose of the study: To our knowledge, only qualitative data is available concerning the tension placed on the first carpometacarpal ligaments as a function of joint motion. The three articles published in the literature have provided discordant data. We conducted a quantitative study. Material and methods:. Digitalized computed tomographies of the carpometacarpal joints magnified threefold were fed to a Stratasys® machine which created a rapid «polystyrene shock» prototype of the first and second metacarpals as well as the trapezium and the trapezoid. After a preliminary study of the behavior observed with various materials, rubber with known consistency was used to simulate the different ligaments. The first metacarpal was submitted to six movements in defined directions starting from the neutral position (in accordance with Pieron, 1973). Ligament lengthening observed for each movement from the resting position of the first metacarpal was used to define the direction producing the greatest lengthening. This lengthening was measured directly with a graduated ruler under 2.5 x optical magnification. Results: The anterior oblique ligament was under tension in the positions close to extension (positions L and D). The posterior oblique ligament was under tension in the position of ulnar finger opposition and in volar abduction (positions K and F). The inter-osseous ligament was under ension in volar abduction, opposition and flexion (positions F, K, J). A complex behavior was observed, best described by two portions, medial and lateral. Discussion: This preliminary study on a model system depended on the interpretation of the ligament and joint surface anatomy. The method of creating joint motion described by Pieron enables comparison between two studies but does not correspond to the physiological position. Conclusion: For a small-sized joint, magnification of the bony pieces and use of optical magnification facilitates apprehension of ligament lengthening during joint motion. This method can be used to better assess maximal range of motion according to ligament deformations observed in relation to joint solicitation

Introduction and aim: In the rheumatoid hand, a radial inclination of the wrist is commonly observed in the presence of an ulnar drift of the fingers. The question that remains is: Which came first? To find an answer to this question, we have studied the radiographs of 122 hand affected by rheumatoid arthritis. Material and methods: In group I (44 hands), the disease was restricted to the wrist joint, which presented an average ulnar inclination of 15°, ranging from neutral to 43° of ulnar inclination. In group II (13 hands), the disease was limited to the MP joints, with an average of 30° of ulnar inclination of the fingers, ranging from 10° to 70°. A compensatory radial inclination of 12° was observed at the wrist, ranging from 2° to 26°. In group III (28 hands), both the wrist and MP joints were affected by the disease. The fingers presented an average ulnar inclination of 17°, ranging from 7° to 40°. The wrist presented an average radial inclination of 4°. In group IV (34 hands) and V (3 hands), measurements were done before and after the finger deformity was corrected from an average of 45° to 7°, while the wrist corrected itself, without wrist balancing procedures, on an average from 30° to 2° of radial inclination. Results: When only the wrist is involved, the metacarpals are always inclined towards the ulnar side. We have observed a radial inclination of the wrist only in the hands presenting an ulnar inclination of the fingers. When the ulnar drift of the fingers is surgically corrected, the radial inclination of the wrist will tend to correct itself. Conclusion: It has been generally accepted that radial inclination of the metacarpals is one of the causes of the ulnar drift of the fingers, but from our studies the radial inclination of the metacarpals should not be considered the cause but rather a consequence of the ulnar drift of the fingers

We describe 22 cases of bizarre parosteal osteochondromatous proliferation, or Nora’s lesion. These are surface-based osteocartilaginous lesions typically affecting the hands and feet. All patients were identified from the records of a regional bone tumour unit and were treated between 1985 and 2009. Nine lesions involved the metacarpals, seven the metatarsals, one originated from a sesamoid bone of the foot and five from long bones (radius, ulna, tibia, and femur in two). The mean age of the patients was 31.8 years (6 to 66), with 14 men and eight women. Diagnosis was based on the radiological and histological features. The initial surgical treatment was excision in 21 cases and amputation of a toe in one. The mean follow-up was for 32 months (12 to 162). Recurrence occurred in six patients (27.3%), with a mean time to recurrence of 49 months (10 to 120). Two of the eight patients with complete resection margins developed a recurrence (25.0%), compared with four of 14 with a marginal or incomplete resection (28.6%). Given the potential surgical morbidity inherent in resection, our data suggest that there may be a role for a relatively tissue-conserving approach to the excision of these lesions

A prospective series of 32 cases with tuberculosis of the hand and wrist is presented. The mean age of the patients was 23.9 years (3 to 65), 12 had bony disease and 20 primarily soft-tissue involvement. The metacarpal of the little finger was the most commonly involved bone. Pain and swelling were the usual presenting features and discharging sinuses were seen in three cases. All patients were given anti-tubercular chemotherapy with four drugs. Operative treatment in the form of open or arthroscopic debridement, or incision and drainage of abscesses, was performed in those cases where no response was seen after eight weeks of ATT. Hand function was evaluated by the modified score of Green and O’Brien. The mean was 58.3 (25 to 80) before treatment and 90.5 (80 to 95) at the end. The mean follow-up was for 22.4 months (6 to 43). Conservative treatment was successful in 24 patients (75%). Eight who did not respond to chemotherapy within eight weeks required surgery. Although tuberculosis of hand has a varied presentation, the majority of lesions respond to conservative treatment

The December 2014 Wrist & Hand Roundup360 looks at: ultrasound for carpal tunnel diagnosis; where we are at with management of undisplaced scaphoid fractures; ARPE for thumb metacarpals?; extravasation injuries in the hand and wrist; research and practice in hand surgery; and physio ineffective in hand osteoarthritis

Purpose: Trapezometacarpal osteoarthritis is frequent in women aged over 50 years. Surgical cure may be needed after failure of well conducted medical treatment. When the trapezeal bone stock is insufficient for implantation of a total prosthesis, total trapezectomy can relieve the pain. This procedure is generally associated with stabilization ligamentoplasty of the first ray. The purpose of this study was to demonstrate the feasibility of this procedure using an arthroscopic approach and to detail the technique and its limitations. Material and methods: This study was conducted on twelve cadaver specimens from eleven women and one man, mean age 85 years. Radiographs were obtained to confirm the trapezometacarpal osteoarthritis. Standard arthroscopic material used for the wrist was employed (2.4 mm optic, mini-shaver). Two portals on either side of the abductor pollicis lungus tendon were used to approach the trapezometacarpal joint. Total trapezectomy was performed with the mini-shaver distal to proximal. A tendon band measuring 6 to 7 cm was fashioned from the abductor pollicis longus tendon via a proximal contraincision. This band inserted on the first metacarpal was passed through two bone tunnels bored in the base of the first and second metacarpals then fixed to the base of the second metacarpal. Operative time was noted. The quality of the bone resection was determined on postoperative radiographs and open inspection. Results: Arthroscopic total trapezectomy with stabilisation ligamentoplasty was achieved in all cases and evaluated radiographically and at open inspection. No lesions to noble elements were observed. Discussion: This minimally invasive technique for trapezectomy associated with stabilisation ligamentoplasty was found to be feasible but did require a certain degree of learning. We were unable to identify any procedure-related morbidity, particularly concerning the sensorial branch of the radial nerve to the thumb. Conclusion: The results of this preliminary study are encouraging and suggest a clinical trial should be conducted to prove the advantages of this technique in terms of morbidity and socioeconomical cost

Allogeneic bone is one of the most commonly used tissue grafts, with a variety of applications in orthopaedic surgery. The aim of this work is to analyze the initial results obtained using allografts in reconstructive surgery of the hand. In the period between January 2000 and August 2003, eight patients between 16 and 52 years of age (average age: 36 years) were treated using an allograft to replace the metacarpal bone and/or phalangeal bone of the hand. In three cases the initial cause was a recurring neoplasm (aneurysm, cyst, osteoma, osteoid, and TGC); in the other patients the aetiology was traumatic. The site of reconstruction was a metacarpal bone in three patients; in two of these it was associated with reconstruction of MPj (in one patient there was double bone loss at the third and fourth metacarpal bone); in one patient the lesion affected only the MPj. In the other five patients the reconstruction was performed at the phalanx, transferring the proximal interphalangeal (PIP) joint as well (except in one case). Different synthesis procedures were performed to obtain a good stability: miniplates, micro-screw, K-wires, and staples. A bone allograft (two cases) was used with platelet gel and a compound of stem cells to promote better recovery of the bone. The patients were followed for a period of between 6 and 40 months after surgery. The time needed to obtain a good healing was on average 6 months (in one case without the proximal recovery of the bone). The total range of movement in fingers that were reconstructed was between 0° and 270°, with an average of 121°. No patient reported any persisting pain. In reconstructive surgery of the hand allografts have only been used occasionally up to now. We believe that this preliminary study provides some useful findings. The waiting time for perfect recovery of a bone before the start of rehabilitation treatment can cause severe stiffness to joints: the osteosynthesis must be as stable as possible to allow for early mobilisation of the joint, especially in post-traumatic cases. Some questions about the future of joint capsules, articular cartilage, and extensor tendons of allograft still remain unanswered. In conclusion, we believe that the results obtained in this preliminary report are encouraging and point towards obtaining a reconstruction of bone loss that is as “biological” as possible

Numerous procedures have been described for degenerative arthritis of the carpometacarpal joint of the thumb. The sling procedure is technically demanding and involves sacrificing part of a healthy tendon. Silicon arthroplasty is associated with stem fracture and synovitis. We have successfully used external fixation for distraction and correction of adduction deformity following trapeziectomy with S-Quattro (Stockport Serpentine Spring System). Following trapeziectomy specially designed pins are inserted into the base of the 1. st. metacarpal and radial styloid and distracted with 2 serpentine springs. The fixator is removed at six weeks and removable thermoplastic splint applied for further 6 weeks. We reviewed the results of 39 trapeziectomy performed in 32 patients (3 male) with an average follow up of 53 months. ROM, power, pinch, pain score and patient satisfaction were reviewed by an independent hand therapist. Average functional score was 28. 9 post-op (maximum 30) compared to 20. 7 pre operatively. Mean thumb abduction was 48. 9 and extension 49. 2 degrees which increased from 42. 9 and 43. 8 pre-operatively. Span was 19 centimetres and opposition 9. 26 on the Kapandji scale. Average grip strength was 40 lbs, pinch strength of 6 lbs and key lateral of 9. 5 lbs. Pain score improved from 7. 9 pre-op to 0. 9. There was statistically significant improvement of all functions except span. Long term follow up radiograph showed good maintenance of gap between base of 1. st. metacarpal and scaphoid. Three cases had deep penetration of the pins, which required early removal. We now insert padding between the fixator and the spring to avoid deep penetration. One patient had mild RSD and another patient had pain in the distribution of the radial nerve, both of which improved following pin removal. Application of S-Quattro following trapeziectomy is a simple and quick procedure. It is reasonably well tolerated by patients. Long-term follow-up showed improvement in hand function and good maintenance of gap between base of 1. st. metacarpal and scaphoid

Various authors have linked hypermobility at the trapeziometacarpal joint to future development of arthritis. When examining hypermobility, the anterior oblique ligament (AOL) and ulnar collateral ligament (UCL) are the two most important supporting structures. Literature suggests that reconstructive techniques to correct the hypermobility can prevent subsequent development of osteoarthritis. Eaton and Littler proposed a surgical technique to reconstruct the ligamentous support of this joint in 1973. This cadaveric biomechanical study aimed to evaluate the resultant effect on the mobility of the thumb metacarpal following this reconstructive technique. Seventeen cadaveric hands were prepared and strategically placed on a jig. Movements at the trapeziometacarpal joint were created artificially. Static digital photographs were taken with intact AOL and UCL at trapeziometacarpal joint (controls), for later comparison with those after sectioning of these ligaments and following Eaton-Littler reconstructive technique. The photographic records were analyzed using Scion.Image. Statistical analysis was performed using Minitab. A paired T-test was used to establish statistical relevance. Results confirmed that the AOL and UCL had a major role in limiting excessive motion at the trapeziometacarpal joint, principally in extension. Division of these ligaments produced a significant degree of subluxation of the metacarpal at this joint with thumb in neutral position (p-value = 0.013). Reconstruction of the ligamentous support using the Eaton-Littler technique reduced the degree of extension available (p-value = 0.005). This study confirmed the important role of the AOL and UCL in maintaining trapeziometacarpal joint stability, and that the Eaton-Littler reconstructive technique reduces the degree of hyperextension at this joint

Fractures of metacarpals and phalanges are common in hand injuries. The goal of treatment is the immediate mobilization of the fingers and restoration of the hand anatomy thus avoiding contractures of the metacarpo-phalangeal and phalangophalangeal joints and hand dysfunction. The aim of this study is the comparison between two methods of fixation of these fractures. Between 2000–2007, 74 patients who suffered meta-carpophalangeal fractures were treated by K-wires and 62 patients were treated by mini external fixation. Parameters recorded were the operating time, postoperative range of motion, cost and complications. The surgical time was lesser with the use of K-wires, the operative technique much simple and the cost minimum as compared to mini external fixators. The postoperative range of motion was inferior with the external fixation. However, there was no statistical difference between the two groups. 2 patients with the external fixation and 1 patient with K-wires developed pin-track infection. There were 3 failures of fixation in the external fixator group but no failure occurred with the use of K-wires. The majority of the fractures healed within 6 weeks. K-wires seem to be the ideal method of treatment considering the fractures of metacarpals and phalanges. The use of mini external fixation presents many disadvantages and probably is restricted to the treatment of the open and comminuted hand fractures

We hypothesized that the finger extensor mechanism has attachments along the dorsal surface of the entire length of the proximal phalanx and that this anatomy has not been clearly defined. The attachment along the dorsal aspect of the proximal phalanx of the index, middle, index and small fingers was dissected in 20 fresh-frozen cadavers. The lateral bands and attachments along the lateral and medial surface were released to appreciate the attachments along the dorsal aspect. We characterized the ligament attachments as very robust, moderately robust, and minimally robust at the distal, middle, and proximal portions. Three orthopaedic surgeons quantified the attachment, finding that 93% of specimens had tendinous attachments and the most robust attachment found at the most proximal and distal aspects adjacent to the articular cartilage. 87% of the specimens had very robust attachments at the proximal portion of the proximal phalanx. The middle portion of the proximal phalanx had moderate to minimally robust attachments. Greatest variability in attachment was found along the most distal portion of proximal phalanx adjacent to the proximal interphalangeal joint (26% of specimens had moderate to minimal robust attachment; 74% had robust attachments). The attachments along the proximal phalanx were attached on the dorsal half of the proximal phalanx, with no fibrous attachments extending past the lateral bands. In summary, we found tendinous attachment along the proximal phalanx that may assist in finger extension and may extend the digit at the metacarpal phalangeal joint without central band contribution

The December 2022 Wrist & Hand Roundup³⁶⁰ looks at: Anti-tumour necrosis factor therapy for early-stage Dupuytren’s disease; Patient experiences of scaphoid waist fractures and their treatment; Postoperative complications following open a1 pulley release for a trigger finger or thumb; How certain are findings in distal radius fractures: a systematic review of randomized controlled trials; Partial wrist denervation in wrist osteoarthritis: patient-reported outcomes and objective function; Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures; How is reduction lost in distal radius fractures in females aged 50 years and older; The HAND-Q: psychometrics of a new patient-reported outcome measure for clinical and research applications.

Extensor tendon attachment to the dorsum of the proximal phalanx may fully extend the finger metacarpal phalangeal joint (MPJ). 15 fresh-frozen cadaveric hands were axially loaded in the line of pull to the extensor digitorum comunis of the index, middle, ring and small finger at the level just proximal to the MPJ. We measured force of extension at the MP joint in 3 groups: 1) native specimen, 2) extensor tendon release at the proximal interphalangeal (PIP) joint with release of lumbricals/lateral bands, 3) extensor tendon release at the PIP joint and dorsal proximal phalanx and lumbrical/lateral band release. Degree change of extension was calculated using arctan function with height change of the distal aspect of the proximal phalanx, and the length of the proximal phalanx. We used Student T-test to determine significant decrease in the extension of the phalanges. Extension of all fingers decreased slightly when the extensor tendon were severed at the PIP joint with release of the lateral bands/lumbricals (8deg+/−2deg). After this release, the finger no longer extended. Slight loss of extension was not statistically significant (p >.05) between group 1 and group 2. Groups 1 and 2 were significantly different compared to group 3. In summary, distal extensor tendon transection and release of lateral bands/lumbricals resulted in little change in force and degree of finger extension. The distal insertion of the extensor, released when exposing the PIP joint dorsally, may not need to be repaired to the base of the middle phalanx

In a prospective study of the measurement of osteoporosis in patients with fracture of the femoral neck, we compared a histological with a radiological method. We found no significant correlation between histological planimetry and the radiological six metacarpal hand index in patients with either cervical or trochanteric fractures. This demonstrates that metacarpal morphometry cannot predict histological osteoporosis of the iliac crest

1. Sixteen cases of thenar paralysis are reviewed in which a bone graft was inserted between the first and second metacarpals to maintain fixed abduction and opposition of the thumb. 2. The technique of the operation is described and the causes of failure are discussed. 3. The operation is intended for those cases in which tendon transplantation to restore active opposition of the thumb is unsuitable. Rotation of the first metacarpal into full opposition is the most important feature of the operation

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Aims

This study aimed to evaluate the effectiveness of the induced membrane technique for treating infected bone defects, and to explore the factors that might affect patient outcomes.

Introduction: Finger length ratio (2d:4d) is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio. Methods: We reviewed 1123 patient records and/or hand x-rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury. Results: 123 Boxer’s fractures were found over a seven month time period, 110 male and 13 female. 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94. Conclusion: Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender

A method of treatment of Bennett's fracture is described. A Kirschner wire is drilled obliquely through the base of the first metacarpal bone and traction is applied in a distal, ulnar and palmar direction in order to counteract the dislocating action of abductor pollicis longus and the flexor muscles. The advantages of the method are: 1) It is technically easy and practically without complications. No important structures are liable to be damaged. 2) It can be used in those cases where the palmar fragment is very small. 3) It can be used for comminuted fractures. 4) It can be used in neglected cases where malunion has occurred. 5) It can be used when there are other fractures of the first metacarpal or adjacent bones. 6) It allows exercises of all the finger joints during the whole period of treatment

Aims

The purpose of this systematic review was to determine the rates of union for vascularized versus non-vascularized grafting techniques in the operative management of scaphoid nonunion. Secondary aims were to determine the effect of the fixation techniques used, the source of grafting, as well as the influence of fracture location (proximal pole) and avascular necrosis (AVN).

Conservative treatment of the ‘boxer’s fracture’ gives acceptable functional results but often leaves the patient with a residual deformity. Using a prograde intramedullary K-wire, we treated 23 consecutive patients with a fractured neck of the fifth metacarpal. Volar angulation exceeded 40°. A 1.6-mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were recorded. All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients, the reduction was anatomical with no residual angulation. In five the residual angulation ranged from 5° to 15°, with a mean of 8°. There was a transient sensory neuropraxia in two patients. This minimally invasive technique is a simple, cost-effective and reliable method of treating a ‘boxer’s fracture’ and ensures a rapid return to full function with little or no residual deformity

Aim: To describe a new radiological sign after rupture of the thumb ulnar collateral ligament. Introduction: Rupture of the thumb ulnar collateral ligament is a commonly missed injury, with delayed diagnosis leading to considerable morbidity. Stress radiographs and MRI scans have been used to diagnose chronic (gamekeepers thumb) or acute (skiers thumb) injuries to this ligament. The former often causes discomfort and the latter are often not readily available. We describe a new radiological sign seen on the lateral radiographs of the thumb, which has previously not been described in the literature. The ‘sag sign’ is volar subluxation of the proximal phalanx in relation to the metacarpal at the metacarpal phalangeal joint. Method: Between 2001–2006, radiographs of nineteen patients who had undergone repair of thumb ulnar collateral ligaments were retrospectively reviewed. There were 12 male and 7 female patients with an average age of 44. These were compared to a control group of normal thumb radiographs. The ‘sag sign’ was present on all the lateral radiographs of thumbs with ulnar collateral ligament tears. Once the ligament was repaired, the metacarpophalangeal joint alignment returned to normal. The sign was validated by senior house officers and registrars in orthopaedics training. Conclusion: The sag sign is a reliable indicator of an underlying injury to the thumb ulnar collateral ligament. Many studies have looked at the radiological diagnosis of this commonly missed injury. Stress radiography and ultrasound require straining an injured thumb which can extend the lesion and cause discomfort. MRI and MR arthrography are both sensitive and specific, but are costly and time consuming. Our sign is evident on plain film, is easily available, and does not require additional apparatus

Prenatal androgen exposure has important organising effects on brain development and influences future behavioural patterns. Second to fourth digit ratio (2D:4D) is a marker for prenatal androgen exposure and as such is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios, a longer fourth finger than second finger, have been shown to be more successful in competitive sports, exhibit increased visuo-spatial ability, more fertile and are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio. We reviewed 1123 patient records and/or hand x rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury. One hundred and twenty three Boxer’s fractures were found over a seven month time period, 110 male and 13 female; 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94. Both ratios were smaller than the published normal digit ratio for the general population. Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender

Introduction and Aims: The ‘Boxer’s fracture’ is a common injury. Often these fractures are treated conservatively with acceptable functional results, leaving the patient with a residual deformity. A minimally invasive technique of treating these fractures was investigated. Method: Twenty-three consecutive patients with a fractured neck of the fifth metacarpal with a volar angulation exceeding 40 degrees were offered treatment with a prograde intramedullary K-wire. All 23 patients accepted this treatment with informed consent. A 1.6 mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were looked at. Results: All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients the reduction was anatomical with no residual angulation. In five, the residual angulation ranged from five to 15 degrees with an average of eight degrees. Two patients suffered a transient sensory neuropraxia. Conclusion: The presented technique is a simple, cost-effective and reliable method of treating a ‘Boxer’s fracture’. Although this type of injury can often be treated without surgery, this procedure ensures a rapid return to full function with little or no residual deformity