Background

Non-operative cases of mallet finger can be followed up by the hand therapists. Both trust and national policies encourage appropriate indication for follow-up in fracture clinic & cost-effective approach without affecting the patient care.

Scaphoid fractures accounts for approximately 15% of all fractures of hand and wrist. Proximal pole fractures represent 10–20% of scaphoid fractures. Non –operative treatment shows high incidence of non-union and avascular necrosis. Surgical intervention with bone graft is associated with better outcome. The aim of this study was to evaluate the radiological and functional outcome of management of proximal pole scaphoid non-union with internal fixation and bone grafting.

We included 35 patients with proximal pole scaphoid non-union (2008–2015). All patients underwent antegrade headless compression screw fixation and bone grafting at King's College Hospital, London (except one, who was fixed with Kirschner wire). 33 patients had bone graft from distal radius and two from iliac crest. Postoperatively patients were treated in plaster for 6–8 weeks, followed by splinting for 4–6 weeks and hand physiotherapy. All the patients were analysed at the final follow-up using DASH score and x-rays.

Mean age of the patients was 28 years (20–61) in 32 men and 3 women. We lost three patients (9%) to follow up. At a mean follow up of 16 weeks (12–18) twenty three patients (66%) achieved radiological union. All patients but three (91%) achieved good functional outcome at mean follow up of 14 weeks (10–16).

A good functional outcome can be achieved with surgical fixation and bone graft in proximal pole scaphoid fractures non-union. Pre-operative fragmentation of proximal pole dictates type of fixation (screw or k wire or no fixation). There was no difference in outcome whether graft was harvested from distal radius or iliac crest.

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.

29 cases of complex elbow injuries were reviewed at a mean period of 15 months. Outcome measures included MEPS and DASH score. Patients who had defined early surgery were significantly better than those in whom surgery was delayed. We concluded that Management of complex elbow injuries can be improved by early definitive surgery. The magnitude and type of soft tissue injuries should be identified. MRI scans should be liberally used for this purpose. We believe that early, adequate and appropriate management of soft tissue injuries including use of articulated external fixator for early mobilisation improves the outcome of complex elbow injuries.

Lunate or perilunate dislocations are common carpal injuries. Current treatment of these injuries by repair or reconstruction of intra-carpal ligaments is largely based on Mayfield's description of sequential failure of these ligaments.

We do treat significant number of these injuries. We have observed that dorsal wrist capsule is attached to dorsal aspect of proximal carpal row and its interosseous ligaments by vertically oriented identifiable fibres. This can be seen as carpal bones suspended from dorsal capsule, akin to cloths suspended from a washing line. We have also observed that in lunate or perilunate dislocations, dorsal capsule is peeled off from the dorsal aspect of lunate and distal radius, similar to a Bankart lesion in the shoulder. We believe that dorsal capsule plays a bigger role in the stabilising mechanism of carpal bone than the intercarpal ligaments. It has not been described before.

We dissected three cadaveric wrists and found vertical fibres running from dorsal wrist capsule/ligaments to the dorsal components of the scapholunate and lunotriquetralinterosseous ligaments. We have modified the Mayo approach to dorsal wrist capsule and use suture anchors to attach dorsal capsule/ligaments to scaphoid, lunate and triquetrum rather than repairing intra-carpal ligament. We have used this technique in 26 patients so far. Follow up for more than 4 years have shown satisfactory results and no significant recurrence of instability.

We present a novel, so far unreported, method of repairing the intracarpal injuries, using the dorsal capsule/ligaments, based on anatomic and intra-operative observations.

Suture anchors have gained popularity in recent years, particularly owing to their ease of use for attaching soft tissues to bone and improved biomechanical properties. Three methods to reattach avulsed finger flexor tendons to the distal phalanx were biomechanically compared: a 1.8mm metal Mitek barbed suture anchor, twin 1.3mm PLA suture anchors (Microfix), or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, 90° to the anchor's axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure.

The results were subject to statistical analysis using Student t test (p< 0.001) and 1-way ANOVA (p<0.0001). The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3mm anchors than the other methods; this method was significantly weaker. The 1.8mm anchor gave similar performance to the pull-out suture and button, while the twin 1.3mm anchors were weaker and vulnerable to gap formation even with passive motion alone.

A suture anchor embedded at between 45 and 90o to the direction of pull gave greater strength than if the pull was in-line. The absorbable 1.3 mm Microfix PLA anchors appeared to be a weak construct, even when twin 1.3 mm anchors were compared to a single metallic 1.8 mm Mitek anchor or the pull-out suture over button technique. All three methods are likely to be satisfactory for reattachment of finger flexor tendons if a low load or non-loading rehabilitation of the hand is planned; however the gap formation on cyclic loading with the Microfix is a concern even if patients are restricted to passive motion.

Aims: To assess the usefulness of wrist arthroscopy in the assessment of symptomatic scaphoid non-unions and associated injuries and to evaluate the implications on the definitive treatment.

Methods: A prospective cohort study of patients undergoing wrist arthroscopy with established scaphoid non-union was performed between January 2006 and April 2009. This study included 17 men and 6 women with a mean age of 39 years.

Results: Majority of the study population (61%) had normal radiocarpal articular cartilage. Articular cartilage wear was mostly limited to the radial styloid and could be effectively debrided. Injuries to the TFCC (39%) followed by the LT joint (35%) and the SL joint (26%) were the most common arthroscopic findings. Other identified pathologies included: Loose bodies, protruding Herbert screw from previous fixation, Chondrocalcinosis, Distal Radio-ulnar joint (DRUJ) instability, Capitohamate (CH) instability and Ulnar styloid fracture non-union. Assessment of the state of the fracture union was best done from the mid carpal joint rather than the radiocarpal joint due to a more prominent fibrocartilage covering of the fracture site from the radiocarpal side Concomitant procedures performed during the wrist arthroscopy included debridement of synovitis (48%) and TFCC repair (4%). Post wrist arthroscopy 6 patients (26%) required a further course of conservative treatment (Physiotherapy +/− local anaesthetic and steroid injection) prior to discharge. In the remaining patients, based upon clinical and arthroscopic findings, a range of other therapeutic and salvage procedures were performed.

Conclusion: This study demonstrates an important role for the wrist arthroscopy in patients with symptomatic scaphoid non-union and in assessing the true extent of the articular cartilage wear and associated carpal injuries. Further it helped in most cases with the decision making in choosing the appropriate definitive surgical option when required.

Split tendons are widely used for reconstructive procedures around wrist and hand. Different materials are used to split the tendons. There is no consensus about the most suitable material for splitting a live tendon. We compared a range of commonly available suture materials to find the best material for the purpose.

11 different suture materials (Vicryl 2/0, Ethibond 0, Ethibond 2/0, Prolene 2/0, Prolene 3/0, Silk 2/0, Steel Wire 2/0, Steel Wire 3/0, Steel Wire 4/0, PDS 2/0, Fibrewire 2/0) were used to split the flexor tendons of pig’s trotters. They were assessed for

their ablity to split the tendon successfully,

Each material was tested on 3 different tendons at different times. Quality of split tendons were assessed by 2 independent and blinded observers.

All suture materials except Vicryl 2/0 were successful in splitting the tendon. Silk produced a poor quality split whilst steel wire and fibre wire resulted in excellent quality grafts. The rest produced intermediate results. The force required to split the tendon was the least for PDS 2/0 followed by Fibrewire. Steel wire and silk required higher forces to split the tendon.

From our study we concluded that fibre wire is the best material to split a live tendon as it produced a high quality split with excellent handling characteristics and required minimal strength. Wire suture produced a high quality split, however they were awkward to use as they necessitated use of a holder due to the higher forces required to split the tendon.

We describe a new technique for fixing the proximal pole scaphoid fractures both in acute and chronic setting and present our preliminary results.

We prospectively studied fixation of 25 proximal pole scaphoid fractures (1 acute displaced and 24 non unions) with this technique between 1999 and 2007. Mean age of patients was 25 years and mean time to the operation was 6 months.

The technique involves making a transverse dorsal incision over the radius along the radio-carpal junction. The retinaculum is split in line with its fibres. Access to the radio-carpal joint is achieved through the third extensor compartment. The ligament attachment to the scaphoid is preserved by using a modified Mayo approach. A window is created initially at the proximal end of the dorsal ridge. The fracture is reduced and stabilised with an appropriate length Herbert screw. The fracture site is curetted through this window and cancellous bone graft from the distal radius is packed into the fracture site. The capsule and extensor retinaculum is then closed in layers.

Radiological union was achieved in 23 cases, one case required refixation and one case was lost to follow up. Our technique is tendon sparing, capsule retaining, and ensures maintenance of articular surface congruity. So far this technique has led to excellent results.

Scaphoid non-union usually requires surgical treatment in form of reconstructive or salvage procedure. Imaging helps in planning the surgical procedure. Wrist arthroscopy may also be helpful in the pre-operative assessment. This study was conducted to find the usefulness of wrist arthroscopy in formulating a management plan to treat scaphoid non-union.

We prospectively studied 17 patients of scaphoid non-unions by wrist arthroscopy. Non-union was assessed; and site and extent of any articular wear if present was noted. Some patients had additional procedures such as synovial debridement, removal of loose bodies or debridement of TFC tears. It was possible to formulate the further management plan at the same time.

Our study included 14 men and 3 women with a mean age of 34.5 years (range 18 to 49). Arthroscopic findings included mild radiocarpal wear in 3 cases and severe articular wear in 1. Additionally, in two thirds of cases there was some degree of wear present over the radial styloid region. 6 cases had TFCC tears. 4 patients had synovial debridement and in 5 cases loose bodies were removed. Based on the arthroscopic findings, it was decided to proceed to a reconstructive procedure in 12 cases and a salvage procedure in remaining 5.

We concluded that in scaphoid non-unions:

Articular surface wear is often less than suggested by imaging.

BACKGROUND: With the improvement of the ultrasound technology, there has been an increasing ability to image the soft tissues of the hand and wrist. This means structures such as tendon, ligaments and soft tissues can be visualized both statically and dynamically.

AIM: The aim of our study was to audit the types of cases who have undergone ultrasound imaging in different hand conditions in last two years.

MATERIAL AND METHODS: We studied 123 ultrasound and looked for its use in different hand and wrist conditions. These were categorized in different groups such as diagnostic, anatomical and therapeutical.

RESULTS: In our 123 patients, 49 had lumps out of which 30 ganglions, 7 vascular, 4 glomus tumours, 2 granulomas, 4 neuromas, 1 lipomas and 1 sarcoma. In another 30 patients it was useful to diagnose tendon conditions such as inflammation, rupture, triggering. Furthermore, in 31 patients it was used for diagnosis of carpal tunnel syndrome. In addition, it was used for many miscellaneous conditions.

DISCUSSION: Ultrasound is a useful tool for imaging of soft tissues in the hand. It can differentiate between solid and cystic swellings and can be used to aspirate and / or inject the later. It allows dynamic viewing thus making it an important tool in assessing complex tendon problems. We feel that it is a convenient, dependable and useful aid in diagnosing various hand conditions and should be available for widespread use.

Three methods to reattach avulsed finger flexor tendons to the distal phalanx were compared: a 1.8 mm metal barbed suture anchor, twin 1.3 mm PLA (polylactic acid)absorbable anchors, or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, and 90 degrees to the anchor’s axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure. The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3 mm absorbable anchors than the other methods; this method was significantly weaker. The 1.8 mm anchor gave similar performance to the pull-out suture over button technique, while the twin 1.3 mm absorbable anchors were weaker and vulnerable to gap formation even with passive motion alone.

The aim of this study was to discover if the ulnar styloid is sufficiently consistent in size, shape and position relative to other bony features of the ulna to be used as a reference in pre-operative planning of fixation of broken bones.

The comparison of size and shape (together known as form) between bones has recently been facilitated thanks to the advance of technologies designed to allow the comparison of the form of structures using anatomical landmarks.

This new class of methods is collectively known as geometric morphometrics. It eliminates the differences in location and rotation of landmark through registration that minimises the sum of squared deviations from each other after scaling. This is Procrustes registration. The residual size and shape information is amenable to statistical analysis. In the present application, the registered Procrustes landmarks are used to compute a mean (reference) shape. The individuals are then compared to this mean/ reference shape. Using principal components analysis (PCA) variations in shape are not only identi-fied, but also quantified. The identification of patterns of deviation from the mean shape is considerably enhanced through the use of 3-D visualistaions of the shape variations represented by the space of the PCA.

These analyses indicate that the ulnar styloid is suf-ficiently consistent in location to other anatomical landmarks that it could be used as a radiographic marker in preoperative planning.

More importantly, the analysis of this study indicates that the methods of geometric morphometrics are widely applicable to the analysis of 3-D variations in morphology facilitating the analysis and comparison of radiographs. A useful future application will be in the development of 3-D reference morphologies that will allow the surgeon to compare and contrast the morphology of a radiograph of a badly broken (comminuted) bone to a standard one. Eventually computer might assist the surgeon by geometrically and visually showing how and by how much the bone needs reduction. Similarly, applications to the the virtual comparison of diseased and healthy bones might allow quantative and visual comparisons that could aid diagnosis and planning.

Suture anchors have changed the practice of repair of tendons in modern Orthopaedics. The purpose of the study was to identify the ideal suture anchor length for anchoring flexor digitorum profundus tendon to the distal phalanx.

We dissected 395 distal phalanges from 80 embalmed hands. Phalanges from two little fingers and three thumbs were damaged, hence were excluded from the study. We measured the Anteroposterior and Lateral dimensions at three fixed points on the distal phalanges of all 395 fingers using a Vernier’s Callipers with 0.1mm accuracy.

The mean value of the Anteroposterior width of the distal phalanx at the insertion of the FDP was found to be 3.4mm for the little finger; 3.9mm for the ring finger; 4.3mm for the middle finger; 4.0mm for the index finger and 5.0mm for the thumb respectively. The commonly available anchors and drill bits were found to be too long when used for anchoring the flexor digitorum profundus tendon in certain distal phalanges. Our findings may be a reason for poor outcome of FDP repair to distal phalanx using suture anchors. New designs for tissue anchors for distal phalanges may be necessary.

Disorders of the pisotriquetral joint can cause ulnar sided wrist pain. This joint is not usually seen during routine wrist arthrosopy because it often has a separate joint cavity. The senior author believes that it is more commonly seen from the 6R portal if looked for, than one would expect from the assumed anatomy.

This study assessed the frequency with which the pisotriquetral joint could be observed in 36 consecutive wrist arthroscopies. The connection between the radiocarpal and the pisotriquetral joint were found to vary from a complete membrane separating the two, to no membrane at all, with variations in between. The types of connections are described. The anatomy of the connections was also studied by dissecting the wrist joints of eight fresh frozen cadavers. The findings matched the arthroscopic observations.

In more than 50% of patients, the pisotriquetral joint could be clearly visualised by arthroscopy. The technique and findings have been recorded on video and form part of the presentation.

Introduction and Aims: To explore the variability of tendon slips, insertions and juncturae tendinae (JT) of extensor digitorum communis (EDC) and extensor digiti quinti proprius (EDQP).

Method: The extensor tendons to digits three, four and five (middle, ring and little fingers respectively) were dissected in 49 adult preserved cadaver hands.

Results: The most common patterns of tendon slip origin/insertion were:

the insertion of two slips from EDQP into digit five (84%);

Whereas variations are not uncommon (Von Schroeder & Botte, 2001), it is the more constant features (presence or absence) which are of surgical relevance and which our study emphasises.

Conclusion: We conclude that the ulnar EDQP slip can be safely and easily harvested as a free tendon graft without any consequential loss of extension of little finger and with minimal surgical trauma. It also follows that rupture of the radial side of the extensor hood of the middle finger predisposes to ulnar subluxation of the middle finger EDC, and we describe two such clinical cases.

Aims: For the scaphoid, several views are needed to visualise the whole bone. These sets of views are routinely called “scaphoid views”. However certain views are better than others for imaging particular parts of the scaphoid. The authors believe that asking for scaphoid views from the radiology department often leads to a wide variety and number of radiographic views being taken, even when a protocol is in place. Methods: 50 radiographers from 4 London teaching hospitals were asked which and how many views of the scaphoid they would take, at initial presentation and in the outpatient setting. They were also asked to describe and demonstrate exactly how they would take the view(s) chosen. Results: We found a wide variation in the descriptive terms used by radiographers for particular views. There was also little agreement on how many and which views to take despite protocols being in place. Conclusion: Not only is their complete lack of agreement on what “scaphoid views” should be, it was also discovered that there was little agreement on the nomenclature of the individual views themselves. This can lead to loss of information from the wrong views being taken as well as unnecessary radiation exposure. The lack of nomenclature also leads to confusion between radiologists, radiographers and surgeons.

Certain cases of patello-femoral maltracking can lead to articular surface wear. Though most can be treated non-operatively, where there is increasing wear surgical intervention may be necessary. Patellar tracking is difficult to assess and though several different types of maltracking or loading have been described, each case warrants precise assessment of the wear patterns. Without this knowledge a logical approach to realignment surgery is impossible.

60 consecutive cases (age range 18–50 years) presenting with anterior knee pain were arthroscoped over a 4 year period. These patients all had been selected with either patellar instability or surface wear indicated either clinically, a positive radiograph, bone scan or MRI.

All patients were arthroscoped through standard anterolateral and antero-medial portals and also a superolateral and occasionally a supero-medial approach. The areas of articular damage were mapped on diagrams and recorded photographically. Patella views were taken in flexion and extension, and on passively stretching the patella medially and laterally.

We found 6 distinct patterns of wear which appear to indicate 6 different maltracking abnormalities. The largest group, 46 patients, consisted of lateral trackers, with 21 patients demonstrating medial facet and lateral femoral condylar wear.

Assessment of the articular surface of the patello-femoral groove from inferior portals is highly misleading and superior portals are needed for proper assessment. Medial facet wear can occur in lateral instability or medial compression. Lateral maltracking at engagement or distally are the commonest patterns.