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Specialty Update   |    
What's New in Hand Surgery
Peter C. Amadio, MD1
1 Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address: amadio.peter@mayo.edu
View Disclosures and Other Information
The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.
Specialty Update has been developed in collaboration with the Council of Musculoskeletal SpecialtySocieties (COMSS) of the American Academy of Orthopaedic Surgeons.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Mar 01;88(3):677-683. doi: 10.2106/JBJS.E.01372
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This update reviews material presented at the 2005 annual meetings of the American Society for Surgery of the Hand (ASSH), the American Association for Hand Surgery (AAHS), and the American Academy of Orthopaedic Surgeons (AAOS) as well as articles published in the field of hand surgery (other than those published in this journal) between August 2004 and July 2005. Meeting abstracts for the ASSH and AAOS annual meetings are maintained online at www.hand-surg.org and www.aaos.org, respectively.
Hand surgery was developed as a specialty to cope with the devastating results of hand injuries in World War II. Sixty years later, trauma remains a prime concern of the hand surgeon and is the focus of much discussion at scientific meetings.
One of the basic tenets of hand surgery has been that accurate surgery requires excellent hemostasis. The metaphor of the watchmaker working in an inkwell was used by Bunnell to convey the point with great effectiveness. Traditionally, tourniquets have been used to achieve hemostasis in the hand. Anecdotes, perhaps apocryphal, of digital loss following the use of local anesthesia with epinephrine have proved effective to discourage the practice for most (but not all) hand surgeons. In a fascinating invited lecture that was delivered to the AAHS, the results of a prospective multicenter study of >3000 cases of hand surgery performed with the patient under local anesthesia with epinephrine (at a concentration of 1:100,000 or less) and the results of a larger retrospective review were presented. The results indicated that hemostasis was excellent without the use of a tourniquet. There were no ischemic complications, even in patients undergoing distal surgery involving the fingers. Procedures performed in this way included flexor tendon repairs (with the benefit of using active motion intraoperatively to check for the integrity of the repair and proper tendon-gliding), fracture fixation, and a variety of soft-tissue procedures. An additional benefit was prolonged postoperative pain relief, without the need for perioperative narcotics. There may be more than one way to drain the inkwell.
Another hand surgery tradition has been the use of skin sutures. This, too, is coming under challenge. In a prospective, randomized trial that was presented to the AAOS, thirty-six patients with nailbed lacerations were randomly assigned to repair with suture or simple cyanoacrylate surgical adhesive. The cosmetic results in the two groups were identical. The cyanoacrylate repair took an average of nine minutes, whereas the suture repair took an average of twenty-seven minutes.
The quintessential subject related to hand surgery research is flexor tendon healing. It is well known that the major problem associated with tendon repair is adhesion formation, i.e., excessive scarring. It is also well known that fetal tissue heals without scar. In a fascinating study presented to the AAHS, researchers sought to determine what would happen if fetal tendon cells were introduced into an adult environment. Was the scar-free healing a property of the cells, their environment, or a result of the interaction of the two? In a model in which adult and fetal sheep tendons were wounded and then implanted into an immunocompromised mouse host, it appears that the property is inherent in the cells: the fetal tendons healed without fibrosis, whereas the adult tendons showed the usual scar reaction, raising the possibility of using fetal cells (or adult cells engineered to behave like fetal cells) to reduce scarring after tendon (or other) injury.
Most hand surgeons would agree that the final result after tendon injury is partly dependent on the nature of the injury, partly dependent on the type and quality of surgical repair performed, and partly dependent on the nature and quality of the postoperative rehabilitation. A prospective, randomized trial compared the results of immobilization with those of early motion in forty-six patients with extensor tendon injuries1. At twelve weeks, there was no difference in terms of final total active motion between the groups, but the early mobilization group had better return of grip strength than the immobilization group did. In a recent Cochrane review, Thien et al. studied the evidence supporting specific therapy strategies after flexor tendon injury2. Insufficient evidence was found to support any specific rehabilitation program. Thus, while there has clearly been an improvement in outcome in going from immobilization (i.e., no therapy, the standard before 1960) to some form of mobilization (the current standard), at present there is little evidence on which to base a preference for specific mobilization protocols.
The treatment of fractures of the distal part of the radius continues to stimulate much research. Several prospective, randomized trials were published recently, all of which resulted in similar conclusions: while more aggressive treatment may result in small but significant differences in anatomic results, functional results are not significantly different, regardless of whether one compares percutaneous pin fixation with internal fixation through a dorsal approach3, percutaneous pin fixation with external fixation4, or percutaneous pins and cast treatment5. A retrospective series led to similar conclusions regarding external fixation and volar fixed-angle plate fixation6, while another retrospective comparison presented to the ASSH demonstrated no difference in functional or radiographic outcome when percutaneous pin fixation was compared with fragment-specific internal fixation. A comparative series of dorsal and palmar plating, presented to the ASSH, showed similar complication rates in association with these two approaches. Thus, while surgery is becoming an increasingly popular option, with case series of various distal radial implants representing fully 20% of the papers presented to the ASSH and several more to the AAOS, evidence to support this clinical choice remains largely limited to case series, with studies with a higher level of evidence demonstrating no or only small clinical differences.
Insurance carriers often wonder whether hand therapy improves outcomes. In the case of distal radial fractures, it appears that the key factor may be adherence to a home exercise program rather than attendance at regular therapy sessions. In a retrospective study of fifteen patients who had been referred for hand therapy after a distal radial fracture, multiple regression analysis showed that more than half of the difference in final motion, hand function, and symptoms could be attributed to the diligence with which the patients adhered to their home exercise program (as recorded in a diary kept by the patients)7.
One explanation for the lack of difference in the clinical outcome associated with the various treatments of distal radial fractures, despite small but significant differences in radiographic parameters, may be found in an interesting presentation to the AAOS, in which fifteen young adults were evaluated thirteen to seventeen years after open reduction and internal fixation of an intra-articular distal radial fracture. All fifteen patients had evidence of posttraumatic arthritis, but the functional results, as assessed with the Musculoskeletal Functional Assessment (MFA) questionnaire, demonstrated that all patients retained good or excellent function. The quality of the final reduction correlated well with the severity of arthritis, but not with function.
Carpal instability is another favorite topic of hand surgeons. One recent study of thirty-one patients who were managed with dorsal capsulodesis for the treatment of chronic static scapholunate dissociation (i.e., a fixed scapholunate gap and scaphoid malrotation on radiographs of the unstressed wrist) suggested that we still have far to go8. Although pain was reduced, strength was unimproved and both motion and scaphoid alignment were worse at a minimum of two years of follow-up. A larger series of 162 patients that was presented to the ASSH demonstrated similar results, while another study that was presented to the AAHS suggested that, whatever its defects, dorsal capsulodesis might still be preferred to other options, such as scaphotrapezial arthrodesis. This latter study was a retrospective review in which fifty-two patients who had been managed with dorsal capsulodesis were compared with thirty-five patients who had been managed with arthrodesis. While pain relief was good in both groups, functional improvement was greater and complications were fewer in the capsulodesis group. Another study of partial scapholunate injuries (i.e., injuries associated with pain and arthroscopically demonstrated scapholunate laxity without radiographic evidence of a scapholunate gap or scaphoid malrotation) suggested that arthroscopic capsular shrinkage may be an option for less severe degrees of instability. In that study, which was presented to the AAHS, good pain relief was reported in fourteen of sixteen patients at an average of nineteen months postoperatively.
In patients with scapholunate instability, the scaphoid is hyperflexed. The opposite displacement, scaphoid extension, occurs in patients with scaphotrapezial arthritis. The reason for this difference has never been clear, but a recent study that was presented to the AAHS suggested a possible explanation. In that cadaveric study, serial sectioning of the palmar scaphotrapezial joint capsule and the flexor carpi radialis insertion was performed to assess the impact on scaphoid rotation. Interestingly, the principal effect appeared to come when the flexor carpi radialis was transected or unloaded. Of course, scaphotrapezial arthritis and flexor carpi radialis tendinopathy are frequently found together. The interesting question is, which comes first? That study suggested that scaphotrapezial arthropathy could be a consequence as well as a cause of flexor carpi radialis pathology.
Does vascularized bone-grafting actually revascularize the lunate affected by Kienböck disease? That was the topic of a study of twenty-six patients who were followed for an average of thirty-one months after treatment with a vascularized graft from the dorsal aspect of the radius9. In addition to symptomatic improvement, 71% of the patients had evidence of revascularization on postoperative magnetic resonance imaging.
As noted in last year's review, arthroscopy is being increasingly used to treat dorsal carpal ganglia. In a recent retrospective series that was presented to the AAOS, open and arthroscopic methods of ganglion excision were compared. Forty-one open and thirty-one arthroscopic excisions were compared at one, four, and eight weeks and at one year after surgery. There was no difference between the two groups with regard to pain, function, or recurrence at any time-point.
Adjacent to the wrist is the often troublesome distal radioulnar joint. In the past, reconstruction has been unreliable for the treatment of distal radioulnar joint instability. More recently, however, anatomic reconstruction of the dorsal and palmar radioulnar ligaments with a tendon graft passed through the fovea at the base of the ulnar styloid, with dorsal and palmar limbs fixed to the distal part of the radius, has been tried. A recent study demonstrated excellent results in seven of nine patients who had been managed in this way10.
When the unstable distal radioulnar joint is affected by arthritis, ligament reconstruction alone will not be sufficient to decrease symptoms and improve function and resection arthroplasty may aggravate the instability of the ulnar stump. In such cases, implant hemiarthroplasty is now an option. A metallic distal ulnar prosthesis is available. In a report to the ASSH, this implant was shown to have good short-term results in twenty-six patients, with all patients reporting a reduction in pain from the preoperative status and with 80% of the patients being satisfied with the result after an average duration of follow-up of thirty months. Implant loosening and "collar" resorption were the main complications, occurring in four and eight cases, respectively. Clearly, though, the high rate of loosening and resorption after a relatively short duration of follow-up should lead to some caution in the use of this device at the present time.
Fracture-dislocations of the proximal interphalangeal joint are often troublesome. Treatment options range from closed reduction and extension block splinting to open reduction and internal fixation to acute osteoarticular grafting. A recent report suggested that, in the case of these fracture-dislocations, less may be more11. Nineteen patients were followed for a minimum of six years after either closed reduction and percutaneous transarticular pin fixation or open reduction and internal fixation. At the time of the most recent follow-up, the patients who had been managed with closed reduction had less pain, less cold intolerance, and better motion, despite having poorer-quality reductions. In that series, the morbidity associated with open reduction appeared to outweigh its advantages in terms of reduction quality.
Year in and year out, carpal tunnel release is the most common surgical procedure on the hand. It stands to reason, then, that carpal tunnel syndrome would be the subject of much research and that there would be something new to report from the past year. One of the more controversial reports was a prospective trial of 101 patients with electrodiagnostically confirmed carpal tunnel syndrome who were randomized to treatment with either steroid injection or surgery12. Patients who had had a previous injection, who had thenar atrophy, or who had conditions known to be associated with carpal tunnel syndrome, such as diabetes mellitus, were excluded. While previous studies had suggested that surgery was a more effective treatment for carpal tunnel syndrome, the results of that report suggested that injection was significantly more effective than surgery in terms of the primary outcome of relief from nocturnal paresthesias at three months. There was no difference between the injection and surgery groups at six and twelve months.
Carpal tunnel syndrome is primarily a condition of middle age, with a peak prevalence between the ages of forty-five and fifty-four years. When younger individuals are affected, there is often a precipitating cause. An interesting report that was presented to the ASSH described the first population-based study of carpal tunnel syndrome during pregnancy. In that study, 12% of more than 2000 pregnant women had development of symptoms of carpal tunnel syndrome, most typically between twenty-eight and thirty-two weeks of gestation. Symptoms persisted post partum in 36% of affected women and, of those, 34% ultimately required surgery. An early return to work outside the home appeared to be associated with persisting symptoms.
Arthritis of the trapeziometacarpal joint is a common ailment, remarkable for the variety of surgical treatment options available; osteotomy, resection arthroplasty of all or part of the trapezium (with or without various ligament reconstruction options), implant arthroplasty with varying designs and materials, and arthrodesis each have their proponents. Several of these options were studied over the past year. In a paper that was presented to the ASSH, the results associated with a new spherical ceramic implant were reported. A total of fifty implants were reviewed after a minimum duration of follow-up of one year. Symptomatic relief and functional results were good, but nearly all patients who had been followed for two years or more showed evidence of implant subsidence, with trapezial fractures in fifteen patients and complete trapezial resorption in one. Interestingly, these complications were not associated with corresponding symptoms or functional loss. A Cochrane review identified seven randomized, quasi-randomized, or controlled trials investigating the surgical treatment of trapeziometacarpal osteoarthritis13. These trials comprised 384 patients who had been managed with trapeziectomy, trapeziectomy with interpositional arthroplasty, trapeziectomy with ligament reconstruction, trapeziectomy with ligament reconstruction and tendon interposition, or joint replacement. The minimum duration of follow-up was one year. Overall, functional results were rather similar among the various treatments, but simple trapeziectomy was associated with significantly fewer complications whereas the ligament reconstruction and tendon interposition procedure was associated with significantly more. Another group of investigators compared the outcomes of trapeziometacarpal arthrodesis, trapeziectomy, and silicone implant arthroplasty in a study of eighty-three patients and concluded that, while clinical outcomes were similar, the complication rate was higher in the arthrodesis group14.
A prospective study that was presented to the ASSH evaluated a new method for the nonoperative treatment of trapeziometacarpal arthritis, namely, the injection of hyaluronic acid in the form of hylan G-F 20 (Synvisc). In that study, sixty patients with symptomatic trapeziometacarpal osteoarthritis were randomized to treatment with placebo, steroid, or hylan injections. At one month, both the placebo and steroid groups demonstrated significant pain relief compared with baseline. At six months, only the hylan group demonstrated significant pain relief compared with baseline. However, none of the differences between the treatment groups themselves, at either time point, reached significance. Thus, while hylan was certainly not worse than placebo or steroid injection, it was not better, either. Clearly, there is room for improvement in the treatment of trapeziometacarpal arthritis.
Finger joint arthroplasty continues to undergo a slow evolution. A recent study evaluated seventy silicone proximal interphalangeal joint implants after a minimum duration of follow-up of three years15. Traumatic, degenerative, and inflammatory arthritis were all represented. The results were mediocre, with no net change in active range of motion. Nine of the seventy implants were revised surgically; a total of eleven implants were fractured at the time of the most recent follow-up. A presentation to the AAHS suggested that newer pyrolytic carbon implants may be better, at least when cemented. A total of twenty-seven cemented and twenty-two uncemented implants were reviewed. After a minimum duration of follow-up of three years, only one of the cemented implants had loosened, while ten of the uncemented implants had loosened and subsided. Final motion and patient satisfaction were not reported.
In the treatment of Dupuytren disease, it is well known that the ability to correct deformity is greater at the metacarpophalangeal joint than at the proximal interphalangeal joint. Does this difference matter to the quality of the result as perceived by the patient? A recent study suggested that it does16. In that study, hand function was measured six and twelve months after surgery in thirty patients with Dupuytren disease. At both six and twelve months, there was a significant correlation between proximal interphalangeal joint correction and hand function but there was no such correlation between metacarpophalangeal joint correction and hand function.
Chronic pain is not typically considered to be an indication for surgery. But what if the pain has elements consistent with nerve compression? A recent review of eight patients (five men and three women) who had development of complex regional pain syndrome after upper-extremity surgery addressed this question17. All patients were found to have distal nerve compression, confirmed with electrodiagnostic testing. Decompression of the affected nerves in these patients was associated with dramatic improvements in terms of pain and function: the average score on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire decreased from 71 to 30. Improvement was observed in terms of hypersensitivity to touch, hyperhydrosis, swelling, cold sensitivity, range of motion, and grip strength. These results suggest that at least some cases of chronic regional pain may represent extreme manifestations of nerve-compression syndromes and that if the evidence to support the diagnosis of nerve compression is strong, surgery may well be an appropriate response.
The last edition of this review mentioned the declining numbers of applicants for hand fellowships. This situation seems to have stabilized, but part of the reason may be a change in the emphasis of hand fellowships, which increasingly provide education for surgery of the entire upper extremity. This matches the interest of many fellowship applicants, who prefer an ultimate practice focused on the entire upper limb, rather than just the most distal part of it. The American Society for Surgery of the Hand has long recognized this trend and now offers continuing education programs in elbow surgery as well as the more traditional hand topics. Fully 25% of the original scientific papers presented to the ASSH in 2005 focused on the shoulder and elbow (and are thus not properly the subject of this review).
The 2003 edition of this report mentioned that Medicare was considering rules that might impair the ability of hand therapists to fabricate splints. This is now much closer to reality as the window for comments on a proposed new Medicare rule on the provision of durable medical equipment closed on November 25, 2005. The proposed rule covers everything from wheelchairs and limb prostheses to prefabricated orthoses. Currently, many hand splints are fabricated out of thermoplastic materials by the therapist treating the patient. This ensures a custom fit and perfect integration with the therapy program. The proposed rule would restrict all splint-making to certified orthotists and prosthetists, who currently have a limited role in the fabrication of splints used in conjunction with hand therapy. The likelihood that therapists could, in the future, forge treatment teams with orthotists and prosthetists is also limited as the rule requires competitive bidding for such durable medical equipment and the only quality standard is the requirement that a certified orthotist or prosthetist be involved. Provision of splints would thus be based on price rather than the presence of some sort of therapeutic relationship or any patient-focused quality measure. It will likely be some time before we know the content of the final rule and more time yet before the new rule will take effect. However, it seems likely that hand surgeons and hand therapists will need to consider new ways to provide splints for their patients in the future.
The Sixty-first Annual Meeting of the American Society for Surgery of the Hand will be held on September 7, 8, and 9, 2006, in Washington, DC. As usual, the ASSH is also offering a variety of continuing medical education (CME) programs throughout the year, including a comprehensive hand surgery review course, to be held on July 14, 15, and 16, 2006, in Chicago, Illinois. The ASSH will also cosponsor courses with the AAHS (see below), the Philadelphia Hand Rehabilitation Foundation, and the AAOS in 2006.
The Thirty-seventh Annual Meeting of the American Association for Hand Surgery will be held January 10 through 13, 2007, in Rio Grande, Puerto Rico. The annual meetings of the AAHS are always held in combination with the annual meetings of the American Society for Reconstructive Microsurgery and the American Society for Peripheral Nerve. These three organizations also share certain management functions, permitting closer integration of their meetings, even offering a combined registration option. They will meet together again in 2008. In 2006, the AAHS will also sponsor a CME program on advances in brachial plexus reconstruction, to be held on April 28, 29, and 30, in Rochester, Minnesota.
All of these meetings are open to all interested parties. Further details will be forthcoming on the society web sites, listed below. The annual meetings of both the American Society for Surgery of the Hand and the American Association for Hand Surgery accept free papers and also feature a wide variety of instructional courses and symposia, many with hands-on sessions. Over the years, as with other maturing organizations, the trend has been for fewer free papers and more symposia and hands-on workshops, including many non-CME-credit industry-sponsored workshops in facilities adjacent to the accredited scientific meeting.
Membership in the two hand surgery societies is restricted to those who have had specific hand surgery training and, in the case of the American Society for Surgery of the Hand, those who have received the Certificate of Added Qualification in Hand Surgery offered by the American Boards of Orthopaedic Surgery, Plastic Surgery, and Surgery. Further information on membership as well as any of the above meetings can be obtained by contacting the organizations directly. Finally, both organizations maintain active web sites, with educational and informational content directed to the public and interested medical professionals, as well as members.
American Society for Surgery of the Hand
6300 North River Road, Suite 600
Rosemont, IL 60018-4256
Telephone: 847-384-8300
Web site: www.hand-surg.org
American Association for Hand Surgery
20 North Michigan Avenue, Suite 700
Chicago, IL 60602
Telephone: 312-236-3307
Web site: www.handsurgery.org
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, eight level-I articles were identified that were relevant to hand surgery. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
Whittaker JP, Nancarrow JD, Sterne GD. The role of antibiotic prophylaxis in clean incised hand injuries: a prospective randomized placebo controlled double blind trial.
J Hand Surg [Br]
.
2005;30:162-7.
One hundred and seventy patients with clean hand injuries were randomize to one of three groups: Group A (one dose of intravenous flucloxacillin followed by oral placebo), Group B (one dose of intravenous flucloxacillin followed by oral flucloxacillin for five days), or Group C (oral placebo only). Exclusion criteria included open fractures, an immunocompromised status, bite wounds, crush wounds, or wounds that were grossly contaminated with soil or grass. The rate of infection (defined as the presence of gross purulence, erythema, swelling, and/or a positive wound culture at one, two, or four weeks) was 13% in Group A, 4% in Group B, and 15% in Group C. None of the differences were significant. A power analysis had assumed an overall infection rate of 5%; the actual rate was 10%. The take-home message from this study is that clean hand wounds may well be more likely to have wound-healing problems, including infection, than is commonly assumed. The trend toward fewer infections in association with the use of antibiotics is certainly logical and supports the common practice of using such drugs. However, additional studies involving more patients are needed to determine the optimal treatment of clean hand wounds.
Jeong GK, Kaplan FT, Liporace F, Paksima N, Koval KJ. An evaluation of two scoring systems to predict instability in fractures of the distal radius.
J Trauma
.
2004;57:1043-7.
One hundred and five patients were prospectively scored with use of the Adolphson and MacKenney formulae to calculate the probability of fracture instability on the basis of presentation parameters. The predicted probability was then compared with the actual results. Ultimately, roughly half of the fractures were found to be unstable after closed reduction. Both systems underestimated the actual instability, with negative predictive values of roughly 50% each. These scoring systems are imperfect guides to treatment. Similar observations have been made in association with other scoring systems. It remains difficult to accurately predict which distal radial fractures will demonstrate instability after closed reduction.
Kharwadkar N, Naique S, Molitor PJ. Prospective randomized trial comparing absorbable and non-absorbable sutures in open carpal tunnel release.
J Hand Surg [Br]
.
2005;30:92-5.
Forty hands were randomized to subcuticular closure with either 3-0 polyglactin 910 (Vicryl) or 3-0 polypropylene (Prolene). There was no difference in scar tenderness between the two groups at two, six, or twelve weeks postoperatively. While most hand surgeons use nonabsorbable skin sutures in the hand, this study suggests that subcuticular closure with absorbable suture is a reasonable alternative.
Moller K, Sollerman C, Geijer M, Kopylov P, Tagil M. Avanta versus Swanson silicone implants in the MCP joint—a prospective, randomized comparison of 30 patients followed for 2 years.
J Hand Surg [Br]
.
2005;30:8-13.
All patients had rheumatoid arthritis. Four fingers were operatively treated in all patients. No difference was noted between the two groups in terms of postoperative pain, function, alignment, or fracture rate. The results were not reported separately by digit. These two implants appear to be roughly similar in terms of the benefit that they offer to patients with rheumatoid arthritis.
Delaney R, Trail IA, Nuttall D. A comparative study of outcome between the Neuflex and Swanson metacarpophalangeal joint replacements.
J Hand Surg [Br]
.
2005;30:3-7.
In this prospective, double-blind trial, twenty-two patients with rheumatoid arthritis were randomized to treatment with either Neuflex or Swanson implants and were evaluated at two years by blinded observers. There was no difference between the two groups in terms of arc of motion, ulnar deviation, grip, function, or implant fracture. There was a significant difference in terms of active flexion, which measured 72° in the Neuflex group and 59° in the Swanson group. As in the study by Moller et al., described above, there appeared to be little difference in outcome among the various designs of hinged silicone metacarpophalangeal joint implants.
Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries.
Cochrane Database Syst Rev
.
2004;3:CD004574.
Four trials were identified, but all were methodologically flawed. There was insufficient evidence to determine if any particular type of splint was better than the others or when surgery might be indicated. Once again, we find that the literature is not sufficiently robust to identify the optimal treatment even for very common conditions such as a mallet finger.
Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires.
J Hand Surg [Br]
.
2004;29:374-6.
A total of fifty-six patients for whom Kirschner wire fixation was indicated for the treatment of distal radial fractures were randomized to have the tips of the wires either buried or left percutaneous with the end bent over to prevent migration. Ten of the twenty-nine wires that were left percutaneous were associated with the development of infection, compared with two of the twenty-seven wires that were buried. The difference was significant (p < 0.05). Unless an infection developed, all pins were left in place for six weeks. While almost all of the percutaneous pins could be removed in the clinic, two-thirds of the buried pins were removed in a day-surgery unit. While the cost of removal of buried pins may be greater, the risk of infection associated with unburied pins is substantial and should be considered, especially when pins are left in place for periods of six weeks or more.
Fagan DJ, Evans A, Ghandour A, Prabhkaran P, Clay NR. A controlled clinical trial of postoperative hand elevation at home following day-case surgery.
J Hand Surg [Br]
.
2004;29:458-60.
In this study of forty-three patients undergoing carpal tunnel surgery, there was no difference in terms of hand swelling (measured volumetrically) or pain at five days postoperatively when patients who had been managed with a sling were compared with those who had been managed with high elevation of the upper extremity by suspension to an intravenous pole.
Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation a prospective trial comparing three rehabilitation regimes. J Hand Surg [Br]. 2005;30:175-9.30175  2005  [PubMed][CrossRef]
 
Thien TB, Becker JH, Theis JC. Rehabilitation after surgery for flexor tendon injuries in the hand. Cochrane Database Syst Rev. 2004;4:CD003979.4CD003979  2004  [PubMed]
 
Kreder HJ, Hanel DP, Agel J, McKee M, Schemitsch EH, Trumble TE, Stephen D. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87: 829-36.87829  2005  [PubMed][CrossRef]
 
Harley BJ, Scharfenberger A, Beaupre LA, Jomha N, Weber DW. Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius—a prospective randomized trial. J Hand Surg [Am]. 2004;29: 815-24.29815  2004  [PubMed][CrossRef]
 
Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br. 2005;87: 837-40.87837  2005  [PubMed][CrossRef]
 
Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg [Am]. 2005;30: 289-99. Erratum in: J Hand Surg [Am]. 2005;30:629.30289  2005  [CrossRef]
 
Lyngcoln A, Taylor N, Pizzari T, Baskus K. The relationship between adherence to hand therapy and short-term outcome after distal radius fracture. J Hand Ther. 2005;18: 2-9.182  2005  [PubMed][CrossRef]
 
Moran SL, Cooney WP, Berger RA, Strickland J. Capsulodesis for the treatment of chronic scapholunate instability. J Hand Surg [Am]. 2005;30: 16-23.3016  2005  [PubMed][CrossRef]
 
Moran SL, Cooney WP, Berger RA, Bishop AT, Shin AY. The use of the 4 + 5 extensor compartmental vascularized bone graft for the treatment of Kienbock's disease. J Hand Surg [Am]. 2005;30: 50-8.3050  2005  [CrossRef]
 
Teoh LC, Yam AK. Anatomic reconstruction of the distal radioulnar ligaments: long-term results. J Hand Surg [Br]. 2005;30: 185-93.30185  2005 
 
Aladin A, Davis TR. Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation. J Hand Surg [Br]. 2005;30: 120-8.30120  2005  [PubMed]
 
Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005;52: 612-9.52612  2005  [PubMed][CrossRef]
 
Wajon A, Ada L, Edmunds I. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2005;4: CD004631.4CD004631  2005 
 
Taylor EJ, Desari K, D'Arcy JC, Bonnici AV. A comparison of fusion, trapeziectomy and silastic replacement for the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg [Br]. 2005;30: 45-9.3045  2005 
 
Takigawa S, Meletiou S, Sauerbier M, Cooney WP. Long-term assessment of Swanson implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg [Am]. 2004;29: 785-95.29785  2004  [PubMed][CrossRef]
 
Draviaraj KP, Chakrabarti I. Functional outcome after surgery for Dupuytren's contracture: a prospective study. J Hand Surg [Am]. 2004;29: 804-8.29804  2004  [PubMed][CrossRef]
 
Placzek JD, Boyer MI, Gelberman RH, Sopp B, Goldfarb CA. Nerve decompression for complex regional pain syndrome type II following upper extremity surgery. J Hand Surg [Am]. 2005;30: 69-74.3069  2005  [PubMed][CrossRef]
 

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References

Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation a prospective trial comparing three rehabilitation regimes. J Hand Surg [Br]. 2005;30:175-9.30175  2005  [PubMed][CrossRef]
 
Thien TB, Becker JH, Theis JC. Rehabilitation after surgery for flexor tendon injuries in the hand. Cochrane Database Syst Rev. 2004;4:CD003979.4CD003979  2004  [PubMed]
 
Kreder HJ, Hanel DP, Agel J, McKee M, Schemitsch EH, Trumble TE, Stephen D. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br. 2005;87: 829-36.87829  2005  [PubMed][CrossRef]
 
Harley BJ, Scharfenberger A, Beaupre LA, Jomha N, Weber DW. Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius—a prospective randomized trial. J Hand Surg [Am]. 2004;29: 815-24.29815  2004  [PubMed][CrossRef]
 
Azzopardi T, Ehrendorfer S, Coulton T, Abela M. Unstable extra-articular fractures of the distal radius: a prospective, randomised study of immobilisation in a cast versus supplementary percutaneous pinning. J Bone Joint Surg Br. 2005;87: 837-40.87837  2005  [PubMed][CrossRef]
 
Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle tine plate versus external fixation. J Hand Surg [Am]. 2005;30: 289-99. Erratum in: J Hand Surg [Am]. 2005;30:629.30289  2005  [CrossRef]
 
Lyngcoln A, Taylor N, Pizzari T, Baskus K. The relationship between adherence to hand therapy and short-term outcome after distal radius fracture. J Hand Ther. 2005;18: 2-9.182  2005  [PubMed][CrossRef]
 
Moran SL, Cooney WP, Berger RA, Strickland J. Capsulodesis for the treatment of chronic scapholunate instability. J Hand Surg [Am]. 2005;30: 16-23.3016  2005  [PubMed][CrossRef]
 
Moran SL, Cooney WP, Berger RA, Bishop AT, Shin AY. The use of the 4 + 5 extensor compartmental vascularized bone graft for the treatment of Kienbock's disease. J Hand Surg [Am]. 2005;30: 50-8.3050  2005  [CrossRef]
 
Teoh LC, Yam AK. Anatomic reconstruction of the distal radioulnar ligaments: long-term results. J Hand Surg [Br]. 2005;30: 185-93.30185  2005 
 
Aladin A, Davis TR. Dorsal fracture-dislocation of the proximal interphalangeal joint: a comparative study of percutaneous Kirschner wire fixation versus open reduction and internal fixation. J Hand Surg [Br]. 2005;30: 120-8.30120  2005  [PubMed]
 
Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005;52: 612-9.52612  2005  [PubMed][CrossRef]
 
Wajon A, Ada L, Edmunds I. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2005;4: CD004631.4CD004631  2005 
 
Taylor EJ, Desari K, D'Arcy JC, Bonnici AV. A comparison of fusion, trapeziectomy and silastic replacement for the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg [Br]. 2005;30: 45-9.3045  2005 
 
Takigawa S, Meletiou S, Sauerbier M, Cooney WP. Long-term assessment of Swanson implant arthroplasty in the proximal interphalangeal joint of the hand. J Hand Surg [Am]. 2004;29: 785-95.29785  2004  [PubMed][CrossRef]
 
Draviaraj KP, Chakrabarti I. Functional outcome after surgery for Dupuytren's contracture: a prospective study. J Hand Surg [Am]. 2004;29: 804-8.29804  2004  [PubMed][CrossRef]
 
Placzek JD, Boyer MI, Gelberman RH, Sopp B, Goldfarb CA. Nerve decompression for complex regional pain syndrome type II following upper extremity surgery. J Hand Surg [Am]. 2005;30: 69-74.3069  2005  [PubMed][CrossRef]
 
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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
CME Activities Associated with This Article
Subspecialty CME | November 15, 2006
Subspecialty CME | May 15, 2006
Quarterly CME | April 05, 2006
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