Study design: Retrospective cross-sectional case series.Background: Lesions of the triangular fibrocartilage complex (TFCC) can result in pain during axial load and unstable distal radioulnar joint (DRUJ). Conventional wrist orthoses decrease initial pain sufficiently but also prevent any movement during recovery and do not contribute to the stabilization of the DRUJ.Purpose: In this retrospective analysis, we tested if the weight-bearing capacity of patients with lesions of the triangular fibrocartilage complex was increased by wearing a brace that stabilizes the distal radioulnar joint.Methods: Twenty-three patients had an arthroscopically confirmed TFCC lesion. We compared preoper-ative dynamic weight-bearing capacity of both hands with and without a commercially available wrist brace (WristWidget). Subgroup analysis was performed for stability of the distal radioulnar joint and eti-ology of the TFCC lesion. The dynamic ulnar variance was measured in a modified weight bearing test. We used parametric tests for normally distributed values.Results: The weight-bearing capacity of the hand with TFCC lesion was significantly lower than of the control hand (16 verus 36 kg; p < 0.001). The relative load of the affected hand compared to the unaf-fected hand increased from 48 % (CI 37-60, SD 27) to 59 % (CI 47-72, SD 29) with a brace. The device had no effect on the control hand. Twelve patients with unstable DRUJ had a lower weight-bearing capacity compared to the eleven with stable joint. The percentage improvement with bracing was higher for those with unstable joints (versus stable) and traumatic lesions (versus degenrative).Conclusion: The use of a wrist brace significantly increases the weight-bearing capacity and therefore the maximum tolerated axial load of patients with a lesion of the TFCC. Patients with traumatic lesion or unstable DRUJ tend to show lower values than with degenerative lesions or stable joints.(c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

Abstract Background To investigate the incidence of osseous wrist and hand injuries on whole-body computed tomographies (WBCT) at an urban maximum-care trauma center, to report the number of missed cases in primary radiology reports, and to develop an algorithm for improved detection of these injuries. Methods Retrospective analysis reviewing all WBCT for a period of 8 months for osseous wrist and hand injuries. (1) Reconstruction of hands/wrists in three planes (thickness 1–2 mm) and analysis by a blinded musculoskeletal radiologist. (2) Scanning of primary radiology reports and comparison to the re-evaluation. (3) Calculation of the diagnostic accuracy of WBCT during primary reporting. (4) Search for factors potentially influencing the incidence (trauma mechanism, associated injuries, Glasgow Coma Scale, artifacts). (5) Development of an algorithm to improve the detection rate. Results Five hundred six WBCT were included between 01/2020 and 08/2020. 59 (11.7%) WBCT showed 92 osseous wrist or hand injuries. Distal intra-articular radius fractures occurred most frequently (n = 24, 26.1%); 22 patients (37.3%) showed multiple injuries. The sensitivity of WBCT in the detection of wrist and hand fractures during primary evaluation was low with 4 positive cases identified correctly (6.8%; 95% CI 1.9 to 16.5), while the specificity was 100% (95% CI 99.2 to 100.0). Forty-three cases (72.9%) were detected on additional imaging after clinical reassessment. Twelve injuries remained undetected (20.3%). Motorcycle accidents were more common in positive cases (22.0% vs. 10.1%, p = 0.006). 98% of positive cases showed additional fractures of the upper and/or lower extremities, whereas 37% of the patients without osseous wrist and hand injuries suffered such fractures (p < 0.001). The remaining investigated factors did not seem to influence the occurrence. Conclusion Osseous wrist and hand injuries are present in 11.7% on WBCT after polytrauma. 93.2% of injuries were missed primarily, resulting in a very low sensitivity of WBCT during primary reporting. Motorcycle accidents might predispose for these injuries, and they often cause additional fractures of the extremities. Clinical re-evaluation of patients and secondary re-evaluation of WBCT with preparation of dedicated multiplanar reformations are essential in polytrauma cases to detect osseous injuries of wrist and hand reliably. Trial registration The study was registered prospectively on November 17th, 2020, at the German register for clinical trials (DRKS-ID: DRKS00023589 ).

Purpose The objective of this study was to evaluate the outcome of a special interdisciplinary hand therapy program depending on the time interval between trauma and rehabilitation. Patients and methods With use of self-assessed scores (Disability of the Arm, Shoulder and Hand Score [DASH-Score], European Quality of Life 5 Dimensions [EQ-5D]) and objective functional parameters (TAM = Total Active Motion for finger injuries, ROM = Range of Motion for wrist injuries, grip strength) the outcome of 76 patients with injuries of the fingers, wrist or a complex regional pain syndrome (CRPS) was analysed at the begin and end of an inpatient rehabilitation and at a follow-up examination after 12 to 16 weeks. The patients were divided into groups with an early (< 120 days after trauma) or late beginning of their rehabilitation. Results At the follow-up examination early beginners had a significant better DASH-Score as well as a ROM. At the end of the rehabilitation program and at the time of the follow-up examination significant more patients with an early as patients with a late start of the rehabilitation were back to work. Especially patients with CRPS and finger injuries benefit from an early start of the rehabilitation. Conclusion Compared to a late start an early start of a rehabilitation program after finger and hand injuries and a CRPS leads to better functional with special benefit for patients with a CRPS.

Darstellung einer nur noch selten durchgeführten Operationstechnik zur Hebung und Implantation eines gefäßgestielten Beckenkammtransplantates ohne die Notwendigkeit von Kenntnissen zu speziellen mikrochirurgischen Techniken oder Komplikationen freier gefäßgestielter Transplantate mit dem Ziel der sicheren Ausheilung von Femurkopfnekrosen. Frühe Stadien der Knochennekrose bis Stadium II nach ARCO (Association Research Circulation Osseous), ggf. frühes Stadium III bis zum Nachweis einer Frakturlinie („crescent sign“), jedoch ohne mechanische Insuffizienz. Femurkopfnekrose in späteren Stadien (ARCO III) mit subchondraler Fraktur und Gelenkeinbruch. Patienten mit mangelnder Fähigkeit zur postoperativen Entlastung oder problematischer Gefäßversorgung durch stattgehabte Radiatio oder Operation an ipsilateralen Leistenlymphknoten, Gefäßanomalien oder schwerer Arteriosklerose. Ausräumen der Femurkopfnekrose und Implantation eines gefäßgestielten Beckenkammspanes. Freie Beugung des Hüftgelenkes nach 4 Wochen postoperativ. Vermeiden der Außenrotation für 3 Monate sowie Entlastung des betroffenen Beines für 3 bis 6 Monate postoperativ in Abhängigkeit der knöchernen Konsolidierung. Vaskularisierte Transplantate zeigen in der Behandlung der Femurkopfnekrose einen deutlichen Vorteil gegenüber avaskulären Transplantaten sowohl radiologisch als auch in der Funktionalität. Trotz der genannten Verbesserungen findet sich im 5‑Jahres-Follow-up im Stadium II durchschnittlich bei 25 % der Patienten ein weiterer radiologischer Progress. Im Stadium III zeigt sich mit allen revaskularisierenden Methoden eine weitere Zunahme der Nekrose mit fortschreitendem Kollaps und der Notwendigkeit der TEP-Implantation im Verlauf. Bei vergleichbarem Outcome nach freier gefäßgestielter Fibula und den wenigen Fällen mit ortsständigem gefäßgestieltem Beckenkammtransplantat muss festgehalten werde, dass die operativen Risiken, neben der anatomisch anspruchsvollen Hebung, trotz biologisch günstigem Transplantat im Vergleich deutlich höher liegen. Heutzutage wird vorwiegend das freie gefäßgestielte Fibulatransplantat für die Behandlung der Femurkopfnekrose angewendet.

Background The aim of this study was to evaluate the potential of whole-body CT for diagnosis of hand and forearm fractures in intubated patients with suspected polytrauma. Methods We performed a retrospective analysis on data collected from two trauma centres in Germany, including demographics, ISS, clinical symptoms, depiction in whole-body CT, and time to diagnosis. Results Out of 426 patients included in the study, 66 (15.5%) suffered a hand or forearm fracture. The total number of fractures was 132, the whole-body CT report mentioned 98 (74.2%). 16 (12,1%) fractures of 12 patients were diagnosed later than 24 h after admission. Late diagnoses of fractures of the hand occurred more often if the hand was not fully included in the CT scan field. The sensitivity of whole-body CT for cases with fractures of hand and/or forearm with full inclusion of the corresponding area in the scan field was 80.2%. Conclusions This study shows that whole-body CT is a valuable diagnostic tool for hand fractures in polytrauma patients. Hands should be evaluated regardless of clinical presentation in intubated patients after suspected polytrauma if they are included in the whole-body CT.

Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck’s disease. We examined if wrist position modifies the blood flow in the nutrient vessels. Retrospective analysis of 17 patients with Kienböck’s disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher’s exact and Wilcoxon-test. We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position. The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

Skaphoidpseudarthrosen nach z. B. proximalen Frakturen oder fehlgeschlagenen Rekonstruktionsversuchen sind mögliche Indikationsbereiche vaskularisierter Knochentransplantate. Hierzu stehen verschiedene vaskularisierte (gestielte und freie) Knochentransplantate zur Verfügung. Gestielte Transplantate aus der unmittelbaren Umgebung des Handgelenkes bieten Vorteile durch geringere Hebemorbidität und allzeit erhaltene Perfusion ohne Notwendigkeit einer Gefäßanastomosierung sowie der damit erwarteten Verbesserung des Einheilungsverhaltens.

BACKGROUND Operative treatment of the scaphoid nonunion includes avascular corticocancellous and cancellous bone grafts and increasingly the use of vascular pedicled and free vascular corticocancellous grafts. Especially the latter require a fair amount of operative expertise and experience in microsurgical techniques. OBJECTIVE Which criteria lead to the decision for or against an avascular graft used for reconstruction of scaphoid nonunion? Is our current classification system of a scaphoid pseudarthrosis able to illustrate our diagnostic potential in a way that makes us refer to operative procedures? METHODS Evaluation of current literature and expert opinions RESULTS: Avascular bone grafts show a high union rate as long as a sufficient vascularisation of the remaining fragments is present. In general, patients benefit from a very good functional outcome. Even revisions of failed scaphoid union may be successfully treated with an avascular bone graft. Failures of union are repeatedly experienced in treating proximal pole fractures with critical vascularisation or extensive bone loss, especially including avascular necrosis of the proximal pole (AVN). Current classification systems do not allow description and correlation of morphologic findings so as to compare results profoundly and to recommend specific procedures. CONCLUSIONS As long as sufficient vascularisation of remaining fragments is seen, the avascular bone graft is eligible for reconstructing scaphoid nonunion. Classification systems do not seem to reflect the status quo of diagnostic possibilities and make it difficult to provide guidelines for state-of-the-art operative procedures.

Für die rekonstruktive operative Therapie der Skaphoidpseudarthrose stehen neben den avaskulären kortikospongiösen und rein spongiösen Transplantaten gestielte und freie gefäßgestielte kortikospongiöse Transplantate zur Verfügung. Insbesondere letztere erfordern einen hohen Anspruch an operative Fertigkeit und mikrochirurgische Erfahrung.

Mit dem Karpaltunnelsyndrom ist 2015 eine weitere Volkskrankheit in die Berufskrankheitenliste unter der BK-Nr. 2113 aufgenommen worden. Aber wann ist ein Karpaltunnelsyndrom auf die berufliche Exposition und wann nicht zurückzuführen? Der Beitrag soll aus der Sicht des Handchirurgen Hinweise für die medizinische Zusammenhangsbegutachtung zur neuen BK 2113 geben unter besonderer Berücksichtigung der wissenschaftlichen Begründung und der zu diesem Thema veröffentlichten Literatur. Auf die Abgrenzungsproblematik zu außerberuflichen konkurrierenden Faktoren bei der Volkskrankheit Karpaltunnelsyndrom wird verwiesen werden. Das Karpaltunnelsyndrom hat das Potenzial, Berufsgenossenschaften, ärztliche Gutachter und Rechtsprechung zu beschäftigen.

BACKGROUND:Advances in basic research evaluating suture material, techniques, and maximum tendon load with regard to repair site failure help to decide between rehabilitation protocols after the repair of flexor tendon injuries.OBJECTIVES:The presentation and choice of rehabilitation protocols depending on the mechanism of injury and knowledge of the influencing factors concerning tendon load. Expected outcome after flexor tendon repair.METHODS:Evaluating recent literature and basic research investigations, and presenting expert opinions.RESULTS:Based on the mechanism of injury, the suture technique, the compliance of the patient, and the latest knowledge on tendon capacity help to choose from the basic principles of rehabilitation protocols: passive or early motion protocols, such as those described by Duran-Houser and Kleinert, in the majority of cases lead to good and fair results according to the Hand Functional Score of the American Society for Surgery of the Hand. A larger number of excellent functional results are seen after the rehabilitation of flexor tendon injuries using combined passive/active or completely active motion protocols, e.g., according to Small. In addition to choosing a specific protocol and considering different zones of injury, it is essential to thoroughly supervise therapy and to monitor the adjustment of splints. It is widely recommended that patients should be provided with additional scar treatment and physical therapy throughout their entire rehabilitation.CONCLUSIONS:Flexor tendon injuries, especially in zone 2, are still a challenge with regard to operative treatment and rehabilitation, with an unpredictable outcome. Further knowledge and advances in suture techniques and material will support the use of active motion protocols and improve functional results in the future.

Der Morbus Dupuytren kann eine erhebliche Funktionsstörungen der Hand durch Bewegungseinschränkungen vor allem der Finger und des Daumens sowie seltener störende manuelle Dysästhesien verursachen. Zur Behandlung ist in der Regel die operative Therapie indiziert. Da die Ausprägungsform des M. Dupuytren sehr variabel ist, sind entsprechend unterschiedliche Therapiekonzepte und operative Vorgehensweisen entwickelt worden. Bei bekannter hoher Rezidivrate ist die Indikation zur operativen Therapie jedoch streng zu stellen. Die Ausprägungsform und andere patientenspezifische Faktoren haben Einfluss auf die Wahl des operativen Zugangs und des Operationsausmaßes. Nachfolgend wird eine Übersicht über gängige Operationsverfahren, das perioperative Management und die Strangpräparation unter anatomischen Gesichtspunkten gegeben.