Hand Fractures in Children: When Do I Need to Start Thinking About Surgery?
Instr Course Lect. 2019;68:415-426
Authors: Case AL, Hosseinzadeh P, Baldwin KD, Abzug JM
Each year, a hand fracture is diagnosed in 24.2 of 100,000 children in Canada. Hand injuries are the most common fractures in children, making up approximately one fifth of all pediatric fractures. The incidence of hand fractures peaks between the ages of 10 and 14 years, with the highest frequencies observed among adolescent males. These increased frequencies coincide with the age at which most children begin playing contact sports, with sport-related injuries found to be the largest cause of adolescent fractures. The fifth digit is the most commonly injured digit, followed by the thumb. Phalangeal fractures constitute approximately 65% of pediatric hand fractures. Metacarpal fractures account for approximately 35% of pediatric and adolescent hand fractures, with 100 of every 100,000 children sustaining a fracture of the metacarpals. The decision to operate is related to many factors and depends on the age of the child and the location and nature of the fracture. The remodeling potential of pediatric bones factors largely into this decision because the phalangeal physis can contribute to bone growth and realignment via remodeling.
PMID: 32032048 [PubMed - indexed for MEDLINE]
Sports Injuries of the Hand, Wrist, and Elbow.
Instr Course Lect. 2019;68:153-166
Authors: Goldfarb C, Dy C, Brogan D, Osei D
Sports injuries of the upper extremity are a common problem seen by those who care for athletes and those who manage upper extremity injuries. The term "high-level athlete" may include adolescents and high school students, collegiate athletes, and of course, the professional athlete. However, the "weekend warrior" can sustain similar injuries and can have a similar desire to return to play as quickly as possible. The challenge in management of these injuries to the elbow, wrist, and hand is identifying those injuries that will benefit from early surgery compared with those that may be safely treated nonsurgically. A rapid return to play may be possible with some injuries with cast or splint immobilization based on the sport and position played. Management of common sports injuries of the hand, wrist, and medial elbow should be reviewed with consideration of return to play.
PMID: 32032034 [PubMed - indexed for MEDLINE]
Methods for Congenital Thumb Hypoplasia Reconstruction. A Review of the Outcomes for Ten Years of Surgical Treatment.
Medicina (Kaunas). 2019 Sep 20;55(10):
Authors: Ozols D, Butnere MM, Petersons A
BACKGROUND AND OBJECTIVES: Congenital thumb hypoplasia is a rare deformity of upper extremity. The incidence for thumb hypoplasia grade II-V is 1:10,000 newborns per year in Latvia. A technique for extensor indicis proprius (EIP) tendon transfer with subperiosteal fixation was developed and used for thumb hypoplasia grades II and IIIa. Pollicization or second-toe-to-hand transplantation with metatarsophalangeal (MTP) joint arthrodesis was used for the reconstruction of hypoplasia grade IIIb-V. The aim of this retrospective cohort study is to evaluate the outcomes for reconstruction techniques used in one surgical center during a ten-year period by one surgeon to evaluate functional and aesthetical outcomes for new techniques.
MATERIALS AND METHODS: In total, 21 patients were operated on during 2007-2017, and 18 of these patients were involved in this study. Long-term follow-up was completed to evaluate the functions and aesthetics of the hands.
RESULTS: disabilities of the arm, shoulder and hand (DASH) was 9.35 (8-10.7) for the second-toe-to-hand with MTP joint arthrodesis transplantation method for pollicization method 19.8 (6-26.7), and for the EIP tendon transposition, 14.54 (0.9-56.3).
CONCLUSIONS: The postoperative functional parameters of congenital hand hypoplasia patients, regardless of the surgical method, are worse than the functional results of healthy patients. The use of the second-toe-to-hand with MTP joint arthrodesis transplantation method provides patients with congenital hand IIIb-V hypoplasia a stable and functional first finger formation. The functional results are comparable to the clinical results of the pollicization method while ensuring the creation of a five-digit hand.
PMID: 31547029 [PubMed - indexed for MEDLINE]
Investigating causal mechanisms in randomised controlled trials.
Trials. 2019 Aug 23;20(1):524
Authors: Lee H, Herbert RD, Lamb SE, Moseley AM, McAuley JH
INTRODUCTION: In some randomised trials, the primary interest is in the mechanisms by which an intervention exerts its effects on health outcomes. That is, clinicians and policy-makers may be interested in how the intervention works (or why it does not work) through hypothesised causal mechanisms. In this article, we highlight the value of understanding causal mechanisms in randomised trials by applying causal mediation analysis to two randomised trials of complex interventions.
MAIN BODY: In the first example, we examine a potential mechanism by which an exercise programme for rheumatoid arthritis of the hand could improve hand function. In the second example, we explore why a rehabilitation programme for ankle fractures failed to improve lower-limb function through hypothesised mechanisms. We outline critical assumptions that are required for making valid causal inferences from these analyses, and provide results of sensitivity analyses that are used to assess the degree to which the estimated causal mediation effects could have been biased by residual confounding.
CONCLUSION: This paper demonstrates how the application of causal mediation analyses to randomised trials can identify the mechanisms by which complex interventions exert their effects. We discuss methodological issues and assumptions that should be considered when mediation analyses of randomised trials are used to inform clinical practice and policy decisions.
PMID: 31443729 [PubMed - indexed for MEDLINE]
Outcome of Recurrent Surgery in Dupuytren's Disease: Comparison with Initial Treatment.
Plast Reconstr Surg. 2019 11;144(5):828e-835e
Authors: Mendelaar NHA, Poelstra R, van Nieuwenhoven CA, Slijper HP, Feitz R, Hovius SER, Selles RW
BACKGROUND: There are multiple studies about the effectiveness of primary treatment in Dupuytren's disease. However, such studies concerning treatment effectiveness of recurrent disease are scarce. Therefore, the primary aim of this study was to compare treatment effectiveness of initial and repeated surgery in patients with Dupuytren's disease.
METHODS: Patients who underwent both initial and repeated treatment were selected from a prospectively maintained database. Outcome measurements consisted of finger goniometry, the Michigan Hand Outcomes Questionnaire, and complications. Treatment effectiveness was defined as improvement in extension deficit and patient-reported hand function. In addition, measurements at intake of both treatments were compared. Subgroup analyses were performed to evaluate influence of type of surgery of initial treatment on outcomes of repeated treatment.
RESULTS: One hundred fourteen patients were included in the analyses. Improvement in extension deficit and Michigan Hand Outcomes Questionnaire outcomes was equal for initial and repeated treatments. Extension deficit and Michigan Hand Outcomes Questionnaire scores were worse at intake of repeated treatment compared to these outcomes at intake of initial treatment. In addition, patients who initially underwent needle fasciotomy achieved a better contracture reduction after repeated treatment.
CONCLUSIONS: This study demonstrates that treatment of recurrent Dupuytren's disease is as effective as initial treatment, despite larger extension deficit and worse self-assessed hand function before undergoing repeated treatment. Complication rates were similar for initial and repeated treatments. Furthermore, needle fasciotomy for initial treatment results in better outcomes of repeated treatment compared to patients who initially underwent limited fasciectomy. These findings can be used for a more evidence-based preoperative counseling with patients with recurrent Dupuytren's disease.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
PMID: 31397794 [PubMed - indexed for MEDLINE]
A potential factor in the pathophysiology of lateral epicondylitis: The long sarcomere length of the extensor carpi radialis brevis muscle and implications for physiotherapy.
Med Hypotheses. 2019 Sep;130:109278
Authors: Bazancir Z, Fırat T
Lateral epicondylitis is a chronic angiofibroblastic degeneration of the origins of the wrist extensor muscles and is characterized by diffuse elbow pain. Although it is the most common syndrome of the elbow joint, the most affected structure is the tendon of the extensor carpi radialis brevis (ECRB) muscle. Several theories have been proposed to explain the pathophysiology of lateral epicondylitis, however, there is no evidence to show that the sarcomere length and microanatomical features of the ECRB muscle can be affected by the elongated position of the muscle. We hypothesized that the tensile response may be the responsible mechanism in the pathophysiology of lateral epicondylitis due to the microanatomy of the ECRB muscle and its functioning in the elongated position. Elongated position leads to elongation of the sarcomere length by forming a functional traction angle in the ECRB muscle. The elongated sarcomere length negatively affects muscular microcirculation. Poor microcirculation triggers ischemia in the muscle and tendon and leads to an increase in immature Type III collagen synthesis. Disruption of the collagen continuity and the loss of load-bearing capacity initiate the neovascularization process. This situation accelerates the degeneration process in the tendon and prevents healing. Furthermore, based on our hypothesis, we recommend new physiotherapy approaches that may contribute to reducing the increased incidence of tendinopathy and to the healing process.
PMID: 31383324 [PubMed - indexed for MEDLINE]
Predicting Carpal Bone Kinematics Using an Expanded Digital Database of Wrist Carpal Bone Anatomy and Kinematics.
J Orthop Res. 2019 12;37(12):2661-2670
Authors: Akhbari B, Moore DC, Laidlaw DH, Weiss AC, Akelman E, Wolfe SW, Crisco JJ
The wrist can be considered a 2 degrees-of-freedom joint with all movements reflecting the combination of flexion-extension and radial-ulnar deviation. Wrist motions are accomplished by the kinematic reduction of the 42 degrees-of-freedom of the individual carpal bones. While previous studies have demonstrated the minimal motion of the scaphoid and lunate as the wrist moves along the dart-thrower's path or small relative motion between hamate-capitate-trapezoid, an understanding of the kinematics of the complete carpus across all wrist motions remains lacking. To address this, we assembled an open-source database of in vivo carpal motions and developed mathematical models of the carpal kinematics as a function of wrist motion. Quadratic surfaces were trained for each of the 42-carpal bone degrees-of-freedom and the goodness of fits were evaluated. Using the models, paths of wrist motion that generated minimal carpal rotations or translations were determined. Model predictions were best for flexion-extension, radial-ulnar deviation, and volar-dorsal translations for all carpal bones with R 2 > 0.8, while the estimates were least effective for supination-pronation with R 2 < 0.6. The wrist path of motion's analysis indicated that the distal row of carpal bones moves rigidly together (<3° motion), along the anatomical axis of wrist motion, while the bones in the proximal row undergo minimal motion when the wrist moves in a path oblique to the main axes. The open-source dataset along with its graphical user interface and mathematical models should facilitate clinical visualization and enable new studies of carpal kinematics and function. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2661-2670, 2019.
PMID: 31378991 [PubMed - indexed for MEDLINE]
A lunate-triquetral coalition from a commingled funerary context from the Chalcolithic Perdigões ditched enclosures of Portugal.
Anthropol Anz. 2020 Feb 13;77(1):83-88
Authors: Godinho RM, Santos AL, Valera AC
Carpal coalitions, resulting from a failure of separation of the cartilaginous precursors of the carpal bones during gestation, may be osseous or non-osseous. Even though lunate-triquetral coalitions are the most common of all carpal coalitions there is only one previous palaeopathological report of such a coalition. This study presents a non-osseous lunate-triquetral coalition found amongst the mostly cremated commingled bones from a Chalcolithic pit at Perdigões (Portugal). The cremated bones show evidence of burning at varying but mostly at generally high temperatures. The perfect articulation between these right bones and pinpoint pitting in the lunate-triquetral joint were crucial for the identification of this congenital condition. Carpal coalitions are more frequent in African than European populations. Artifacts produced from ivory of African origin were found in Perdigões, however it is not possible to establish the ancestry of this individual.
PMID: 31322644 [PubMed - indexed for MEDLINE]
Do wrist buckle fractures in children need follow-up? Buckle fractures' follow-up.
J Pediatr Orthop B. 2019 Nov;28(6):553-554
Authors: Riera-Álvarez L, Pons-Villanueva J
Buckle or torus fractures in the distal forearm are characterized by a bulging of the cortical bone. They are a frequent reason for consultation in pediatric emergencies. The treatment and follow-up of this type of fractures varies from soft immobilizations to a plaster cast. The purpose of this study is to assess the stability of buckle fractures of the distal radius. We reviewed 106 pediatric patients with buckle fractures and analyzed the radiographs at the time of initial consultation and at the last follow-up. None of these fractures displaced further, regardless of the treatment given. Buckle or torus fractures do not need follow-up radiographs. As they are stable, the simpler immobilization treatment is sufficient.
PMID: 31305367 [PubMed - indexed for MEDLINE]
The Maternal and Paternal Effects on Clinically and Surgically Defined Osteoarthritis.
Arthritis Rheumatol. 2019 11;71(11):1844-1848
Authors: Weldingh E, Johnsen MB, Hagen KB, Østerås N, Risberg MA, Natvig B, Slatkowsky-Christensen B, Fenstad AM, Furnes O, Nordsletten L, Magnusson K
OBJECTIVE: It is currently unknown whether osteoarthritis (OA) is inherited mainly from the mother, father, or both. This study was undertaken to explore the effect of maternal and paternal factors on hip, knee, and hand OA in offspring.
METHODS: Participants from the Musculoskeletal Pain in Ullensaker Study (MUST) (69% female; mean ± SD age 64 ± 9 years) and a Norwegian OA twin study (Nor-Twin) (56% female; 49 ± 11 years) reported whether their mother and/or father had OA. Using a recurrence risk estimation approach, we calculated whether maternal and paternal OA increased the risk of 1) surgically defined hip and knee OA (i.e., total joint replacement) and 2) clinically defined hip, knee, and hand OA (i.e., the American College of Rheumatology criteria) using logistic regression. Relative risks (RRs) with 95% confidence intervals (95% CIs) were calculated.
RESULTS: Maternal OA consistently increased the risk of offspring OA across different OA locations and severities. Having a mother with OA increased the risk of any OA in daughters (RR 1.13 [95% CI 1.02-1.25] in the MUST cohort; RR 1.44 [95% CI 1.05-1.97] in the Nor-Twin cohort) but not (or with less certainty) in sons (RR 1.16 [95% CI 0.95-1.43] in the MUST cohort; RR 1.31 [95% CI 0.71-2.41] in the Nor-Twin cohort). Having a father with OA was less likely to increase the risk of any OA in daughters (RR 1.00 [95% CI 0.85-1.16] in the MUST cohort; RR 1.52 [95% CI 0.94-2.46] in the Nor-Twin cohort) and sons (RR 1.08 [95% CI 0.83-1.41] in the MUST cohort; RR 0.93 [95% CI 0.35-2.48] in the Nor-Twin cohort).
CONCLUSION: OA in the mother increased the risk of surgically and clinically defined hip, knee, and hand OA in offspring, particularly in daughters. Our findings imply that heredity of OA may be linked to maternal genes and/or maternal-specific factors such as the fetal environment.
PMID: 31237417 [PubMed - indexed for MEDLINE]
Biomechanical analysis of metacarpophalangeal joint arthroplasty with metal-polyethylene implant: An in-vitro study.
Clin Biomech (Bristol, Avon). 2019 02;62:79-85
Authors: Melo D, Completo A, Nascimento A, Fonseca F
BACKGROUND: The most common implant options for the metacarpophalangeal joint arthroplasty include silicone, pyrocarbon and metal-polyethylene. A systematic review of outcomes of silicone and pyrocarbon implants was conducted; however, a similar exercise for metal-polyethylene implants revealed a scarcity of published results and lack of long-term follow-up studies. The aim of the present work is to test the hypothesis that the magnitude of metacarpophalangeal joint cyclic loads generates stress and strain behaviour, which leads to long-term reduced risk of metal-polyethylene component loosening.
METHODS: This study was performed using synthetic metacarpals and proximal phalanges to experimentally predict the cortex strain behaviour for both intact and implanted states. Finite element models were developed to assess the structural behaviour of cancellous-bone and metal-polyethylene components; these models were validated by comparing cortex strains predictions against the measurements.
FINDINGS: Cortex strains in the implanted metacarpophalangeal joint presented a significant reduction in relation to the intact joint; the exception was the dorsal side of the phalanx, which presents a significant strain increase. Cancellous-bone at proximal dorsal region of phalanx reveals a three to fourfold strain increase as compared to the intact condition. Interpretation The use of metal-polyethylene implant changes the strain behaviour of the metacarpophalangeal joint yielding the risk of cancellous-bone fatigue failure due to overload in proximal phalanx; this risk is more important than the risk of bone-resorption due to the strain-shielding effect. By limiting the loads magnitude over the joint after arthroplasty, it may contribute to the prevention of implant loosening.
PMID: 30710796 [PubMed - indexed for MEDLINE]
Inhibition of radiographic progression in psoriatic arthritis by adalimumab independent of the control of clinical disease activity.
Rheumatology (Oxford). 2019 06 01;58(6):1025-1033
Authors: Landewé R, Ritchlin CT, Aletaha D, Zhang Y, Ganz F, Hojnik M, Coates LC
OBJECTIVES: To evaluate the relationship between radiographic progression and disease activity in subjects with PsA treated with adalimumab (ADA) or placebo (PBO) and the impact of concomitant MTX.
METHODS: This was a post hoc analysis of the randomized, double-blind, PBO-controlled ADEPT trial. Subjects were categorized according to time-averaged (TA) disease activity (remission, low, moderate or high) based on Disease Activity Score of 28 joints with CRP [DAS28(CRP)], Disease Activity Index for Psoriatic Arthritis (DAPSA) or Psoriatic Arthritis Disease Activity Score (PASDAS), and achievement of minimal disease activity (MDA) at week 24. Radiographic progression was assessed as change in modified total Sharp score (ΔmTSS) from baseline to week 24. The analyses included interaction terms between disease activity and treatment on radiographic progression, comparison of radiographic progression in subjects categorized by disease activity and treatment, and correlation between disease activity and radiographic progression by treatment.
RESULTS: The interaction terms for TA disease activity and treatment on ΔmTSS were significant (P = 0.002-0.008). Irrespective of concomitant MTX, ΔmTSS was lower with ADA vs PBO in all disease activity categories. Importantly, even in subjects having moderate or high disease activity or not achieving MDA, ΔmTSS was significantly lower on ADA than PBO (P = 0.05-0.001 for TA-DAPSA, TA-PASDAS and MDA). Correlations between TA disease activity scores and ΔmTSS were moderately positive and significant (P < 0.001) with PBO but non-significant with ADA.
CONCLUSION: Among subjects with PsA treated with ADA, there was evidence of a 'disconnect' between disease activity and radiographic progression: inhibition of radiographic progression was greater than expected based on control of clinical disease activity alone. MTX had no added effect.
TRIAL REGISTRATION: ClinicalTrials.gov, http://clinicaltrials.gov, NCT00646386.
PMID: 30608620 [PubMed - indexed for MEDLINE]
The Tuck sign-proliferative extensor tenosynovitis of the wrist.
Joint Bone Spine. 2019 05;86(3):385
Authors: Achilleos KM, Gaffney K
PMID: 30528548 [PubMed - indexed for MEDLINE]