Radial polydactyly: proposal for a new classification system based on the 159 duplicated thumbs.

BACKGROUND: Polydactyly is one of the most common congenital differences that affect the hand. It has various anatomic and morphologic features. Although the Wassel classification has been used widely for radial polydactyly, it is based on the anatomic level of duplication and has some limitations in describing the concrete morphology of the duplication. The authors devised a new classification system based on the anatomic pattern of duplication to facilitate surgical correction of the deformity and evaluated surgical outcomes. METHODS: A total of 159 duplicated thumbs in 142 patients who were treated surgically from 1990 to 2007 and followed for > 12 months were included in this series. The authors categorized all cases of radial polydactyly into the following: type I (joint type), where the extra digit has its own joint at its origin; type II (single epiphyseal type), where the origin of the extra digit is derived directly from the common epiphysis; type III (osteochondroma-like type), where the origin of the extra digit resembles an osteochondroma; and type IV (hypoplastic type), where the extra digit is connected to the main digit by soft tissue alone. All patients underwent surgical treatment based on this classification. The surgical outcomes were assessed using the Tada score. RESULTS: Of the 159 radial polydactyly cases, 84 (50%) were classified as the joint type-37 (22%) as the osteochondroma-like type, 33 (19%) as the single epiphyseal type, and 15 (9%) as the hypoplastic type. All the cases were classified with the proposed classification system. In the evaluation of the surgical outcomes, 134 (84%), 17 (11%), and 8 (5%) were rated as good, fair, and poor, respectively. CONCLUSIONS: This new classification system for radial polydactyly is practical and closely related to the surgical strategies. LEVEL OF EVIDENCE: Diagnostic IV.

Vitamin D levels in post-menopausal Korean women with a distal radius fracture.

INTRODUCTION: The purpose of this study was to investigate serum levels of vitamin D in post-menopausal Korean women with a distal radius fracture (DRF) and to determine if there is any association between vitamin D levels and bone-related variables such as bone mineral densities (BMDs), serum parathyroid hormone (PTH) levels and several bone turnover markers. MATERIALS AND METHODS: The data of 104 postmenopausal women surgically treated for a distal radius fracture (DRF group) and 107 age-matched control patients without a fracture (control group) were compared. Serum vitamin D levels (25-hydroxycholecalciferol, 25(OH)D(3)) were compared between the groups with consideration of age and seasonal variations. BMDs, serum PTH and several bone turnover markers, including serum osteocalcin, C-telopeptide and urine N-telopeptide, were measured and analysed to find any association with vitamin D levels. RESULTS: The mean 25(OH)D(3) level was significantly lower in the DRF group compared to the control group (p < 0.001). In particular, patients in their sixth and seventh deciles in the DRF group had significantly lower 25(OH)D(3) levels than patients in the control group (p = 0.001 and 0.013, respectively). When seasonal variation was considered, significant differences of 25(OH)D(3) levels were found between the groups in autumn and winter. Hip BMDs were significantly lower in the DRF group than in the control group, and there was a positive correlation between serum 25(OH)D(3) levels and hip BMDs. Bone turnover markers were not significantly different between the two groups, although serum PTH levels were marginally higher in the DRF group (p = 0.08). CONCLUSIONS: Post-menopausal Korean women with a DRF were found to have significantly lower serum vitamin D levels than the control group, and vitamin D levels were particularly lower in women in their sixth and seventh deciles who may be a good target group for prevention of future fractures. Future investigation should focus on determining whether vitamin D supplementation can be helpful in preventing future fractures in patients with a DRF.

Patients' preferred and retrospectively perceived levels of involvement during decision-making regarding carpal tunnel release.

BACKGROUND: Patient-centered care requires physicians to respond to patients' preferences, including their preferences regarding treatment decision-making. The authors surveyed patients to determine their preoperative preferences and their retrospectively perceived levels of involvement in decision-making for carpal tunnel release, and they attempted to identify factors that affect patient preferences and experiences. METHODS: Seventy-eight patients who underwent carpal tunnel release for carpal tunnel syndrome were requested to indicate their preferred level of involvement preoperatively and to assess their actual levels of involvement postoperatively, using a Control Preferences Scale containing five levels that range from fully active to fully passive. Clinical and demographic factors that potentially affected patients' preoperative preferences and postoperative assessments of levels of involvement were analyzed. RESULTS: Fifty-nine patients (76%) indicated preoperatively that they preferred shared decision-making, and sixty-six (85%) thought postoperatively that they had experienced this type of decision-making. The correlation between preoperative and postoperative Control Preferences Scale assessments was significant (r = 0.525, p < 0.001). A history of a surgical procedure was independently associated with a preoperative preference for a more active role (odds ratio = 4.2), and patients with a caregiver (odds ratio = 4.0) or private insurance (odds ratio = 2.6) were more likely to experience an active role. Patients who preferred a collaborative role had lower scores on the Disabilities of the Arm, Shoulder and Hand questionnaire than those who preferred a fully active role (p = 0.002) or a fully passive role (p = 0.009). CONCLUSIONS: The majority of patients with carpal tunnel syndrome preferred to share surgical decision-making with the surgeon, and those who preferred a collaborative role had less severe symptoms than those who preferred a fully active or a fully passive role. A history of a surgical procedure, having a caregiver, and having private insurance were associated with a more active role. This information may assist the establishment of patient-centered consultation in patients with carpal tunnel syndrome.

Congenital differences of the upper extremity: classification and treatment principles.

For hand surgeons, the treatment of children with congenital differences of the upper extremity is challenging because of the diverse spectrum of conditions encountered, but the task is also rewarding because it provides surgeons with the opportunity to impact a child's growth and development. An ideal classification of congenital differences of the upper extremity would reflect the full spectrum of morphologic abnormalities and encompass etiology, a guide to treatment, and provide prognoses. In this report, I review current classification systems and discuss their contradictions and limitations. In addition, I present a modified classification system and provide treatment principles. As our understanding of the etiology of congenital differences of the upper extremity increases and as experience of treating difficult cases accumulates, even an ideal classification system and optimal treatment strategies will undoubtedly continue to evolve.

Responsiveness of the Korean version of the disabilities of the arm, shoulder and hand questionnaire (K-DASH) after carpal tunnel release.

BACKGROUND: The Korean version of the Disability of the Arm, Shoulder and Hand Questionnaire (K-DASH) was recently validated, but its responsiveness, which is the degree to which an instrument is sensitive to change, has not been thoroughly evaluated in a specific condition in Koreans. We evaluated the responsiveness of the K-DASH in a homogenous cohort of patients with carpal tunnel syndrome (CTS) and we compared it with that of the disease-specific Carpal Tunnel Questionnaire (CTQ). METHODS: Fifty-six patients with CTS prospectively completed the K-DASH and CTQ before and 6 months after surgery. The responsiveness statistics were assessed for both the K-DASH and CTQ by using the standardized response mean (SRM) and the effect size (ES). Pearson correlation coefficients were calculated between the K-DASH and CTQ. RESULTS: The SRM and ES of the K-DASH were all 0.8. The SRM of the symptom and function part of the CTQ was 1.5 and 1.1, and the ES was 1.5 and 1.1, respectively. The K-DASH had moderate correlations with the symptom and function parts of the CTQs, but the postoperative K-DASH had a weak correlation with the symptom part of the postoperative CTQ. CONCLUSIONS: The K-DASH was found to have a large degree of responsiveness (SRM, ES ≥ 0.8) after carpal tunnel release in Korean patients with CTS, which is comparable to the other language versions of the DASH. Although it was less responsive than the CTQ, which is disease-specific, the region-specific K-DASH can be used as an effective outcome measurement tool for CTS, and especially for research that compares CTS with other upper limb conditions.

Cleft hand in Kabuki make-up syndrome: case report.

Kabuki make-up syndrome (KMS) is a multiple malformation/mental retardation syndrome that was first described in Japan but is now reported in many other ethnic groups. Kabuki make-up syndrome is characterized by multiple congenital abnormalities: craniofacial, skeletal, and dermatoglyphic abnormalities; mental retardation; and short stature. Common hand anomalies associated with KMS include persistent fingertip pad, brachydactyly, clinodactyly, and lax joints. We report a patient with KMS who presented with cleft hand, a feature that has not yet been described in KMS, and describe the potential genetic cause.

The origin of regenerating axons after end-to-side neurorrhaphy without donor nerve injury.

The purpose of this study was to determine the origins of regenerated axons after end-to-side neurorrhaphy (ETSN) without donor nerve injury by comparing the time of appearance of regenerating axons for proximally coapted ETSN and distally coapted ETSN. Thirty rabbits were used in each group. In the proximal ETSN group, the ulnar nerve was transected and the distal end sutured to the median nerve 3cm above the elbow joint, whereas in the distal ETSN group, it was 3cm below the elbow joint. Coaptation was performed by wrapping the aponeurosis of nearby muscle. Observations were made weekly for 6 weeks after ETSN. Axonal regeneration was studied by morphometric analysis and immunohistochemistry. The times of appearance of regenerating axons differed in the proximal and distal ETSN groups. Axonal densities in proximal segments of donor nerves continuously increased and the axonal diameters of proximal segments of donor nerves continuously decreased with time after ETSN. Our findings suggest that regenerated axons after ETSN without donor nerve injury originate from the central nervous system rather than coaptation sites.

The effect of muscle excursion on muscle recovery after tendon repair in a neglected tendon injury: a study in rabbit soleus muscles.

We attempted to determine whether muscle excursion observed during operation can be a prognostic indicator of muscle recovery after delayed tendon repair in a rabbit soleus model. Eighteen rabbits underwent tenotomy of the soleus muscles bilaterally and were divided into three groups according to the period from tenotomy to repair. The tendons of each group were repaired 2, 4, and 6 weeks after tenotomy. The excursion of each soleus muscle was measured at the time of tenotomy (baseline), at 2, 4, 6 weeks after tenotomy, and 8 weeks after tendon repair. The amount of muscle recovery after tendon repair in terms of muscle excursion independently depended on the timing of repair and on the muscle excursion observed during repair. The regression model predicted that the muscle excursion recovered on average by 0.6% as the muscle excursion at the time of repair increased by 1% after adjusting for the timing of repair. This study suggests that measuring the muscle excursion during tendon repair may help physicians estimate the potential of muscle recovery in cases of delayed tendon repair.

Evaluation of early postoperative pain and the effectiveness of perifracture site injections following volar plating for distal radius fractures.

PURPOSE: Few studies have investigated the effectiveness of early postoperative pain control regimens after volar plating for distal radius fractures. This study evaluated postoperative levels of pain after volar plating of distal radius fractures under axillary nerve block in patients with and without injections of local anesthetics, narcotics, and epinephrine around the fracture site. METHODS: Perioperative pain levels were prospectively assessed in 44 consecutive patients who had had volar plating for a distal radius fracture under axillary nerve block at a mean time of 2.8 days after trauma. Intravenous, patient-controlled analgesia and prescheduled analgesic medications were administered to all patients. In addition, patients were randomly allocated to 2 groups: perifracture site injection (PI; n = 22) and no perifracture site injection (no-PI; n = 22). At the end of surgery, PI group patients were administered perifracture site injections and blocks of the superficial radial and interosseous nerves with a local anesthetic mixture consisting of ropivacaine, morphine, and epinephrine. During the first 48 hours after surgery, pain visual analog scale (VAS) scores (0 to 100), total amount of narcotic consumption, incidences of additional narcotic requirement, and opioid-related side effects were assessed. RESULTS: The overall mean pain VAS scores among all 44 study subjects were 29 before surgery, and 58, 47, 40, and 27 at 4, 8, 24, and 48 hours after surgery, respectively. Thirteen patients needed additional pain rescue despite the multimodal analgesic approach used. No intergroup differences were observed between the PI and no-PI groups in terms of VAS pain scores, total narcotic consumption, adjuvant pain rescue incidence, and opioid-related side effects. CONCLUSIONS: Postoperative mean pain VAS scores after volar plating of distal radius fractures were found to be 58 at 4 hours and 47 at 8 hours. Perifracture site injections were not found to provide any additional pain control benefit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Age- and site-related bone mineral densities in Korean women with a distal radius fracture compared with the reference Korean female population.

PURPOSE: To assess age- and site-related bone mineral density (BMD) values in Korean female patients with a distal radius fracture, and to compare them with those of the community-based general Korean female population. METHODS: For this study, we recruited 54 consecutive Korean women, 50 to 79 years of age, with a distal radius fracture caused by minor trauma. We performed dual-energy x-ray absorptiometry scans at central sites: the lumbar spine, femoral neck, trochanter, and Ward's triangle, which is a triangular area within the femoral neck. Age- and site-related BMDs were assessed and compared with those of population-based reference data for Korean women. RESULTS: The overall prevalence (defined as meeting the osteoporosis criteria in at least one of the earlier-described measurement areas) of osteoporosis in patients with a distal radius fracture was 57%. The site-related prevalence was 54% at Ward's triangle, 43% at the lumbar spine, 32% at the femoral neck, and 26% at the trochanter, and these values were individually statistically significantly higher than those of the general Korean female population except for the lumbar spine. In patients 50 to 59 and 70 to 79 years of age, patients' mean BMD values at the hip were statistically significantly lower than those of the reference female population of corresponding age groups, but the hip BMD differences were not statistically significant in patients 60 to 69 years of age. There were no statistically significant BMD differences measured at the lumbar spine in any age group. CONCLUSIONS: Korean female patients with a distal radius fracture, 50 to 59 and 70 to 79 years of age, had lower BMDs at the hip than the reference Korean female population. However, no statistically significant BMD differences were found in those 60 to 69 years of age. Low BMD may have a greater impact on distal radius fracture in women younger than 60 years of age or over 70 years of age. Considering the young onset of bone loss, patients younger than 60 years of age with a distal radius fracture are a good target group for secondary prevention of osteoporosis.

Incidence of clinically diagnosed and surgically treated carpal tunnel syndrome in Korea.

PURPOSE: Most epidemiologic studies on carpal tunnel syndrome (CTS) have been performed on specific regional or occupational groups, or on general populations in the West. The authors undertook to determine the incidence of clinically diagnosed and surgically treated CTS in the Korean general population. METHODS: A retrospective, nationwide cohort study was performed using data collected from 2005 to 2007 (inclusive) by the Korean Health Insurance Review Agency, which covers 97% of the population. We analyzed the incidence of clinically diagnosed, electrophysiologically diagnosed, and surgically treated CTS in patients aged over 20 years, and the influences of gender and age on incidence. RESULTS: The incidence of total clinically diagnosed CTS and electrophysiologically diagnosed CTS in patients over 20 years of age was 4.96 and 0.98 per 1,000 person-years, respectively. The incidence of surgically treated CTS was 0.29 per 1,000 person-years. The age-adjusted female to male incidence ratio of diagnosed CTS was 2.58 (95% confidence interval, 2.56-2.59) and that of surgically treated CTS was 5.82 (95% CI, 5.64-6.00). Women aged 50 to 59 years had the highest incidence of CTS (18.11 per 1,000 person-years), whereas men showed a slow increase in incidence with age, highest at 60 to 69 years. CONCLUSIONS: Compared with Western studies, our study of the Korean population shows a similar incidence of CTS but a lower incidence of surgery. Korean women with CTS are more likely to be treated surgically than men. Further studies may be warranted to identify ethnic, gender, and socioeconomic factors that influence surgical treatment rates.

Wrist arthrodesis with volar plate fixation in cerebral palsy.

Wrist arthrodesis can obtain better appearance, hygiene, and ease of daily care, with some degree of functional improvement in patients with cerebral palsy with a severe wrist flexion deformity. Rigid fixation using a dorsal plate and screws has been accepted as a reliable technique, although hardware-related problems are relatively common. We describe a volar plate fixation technique for wrist arthodesis in cerebral palsy, which can allow concomitant flexor tendon release and avoid a prominent hardware and a cosmetically undesirable scar on the dorsum of the wrist.

Failure of the interosseous membrane to heal with immobilization, pinning of the distal radioulnar joint, and bipolar radial head replacement in a case of Essex-Lopresti injury: case report.

The authors report a case of a patient with complex radial head and ulnar shaft fractures with an associated tear of the interosseous membrane, which failed to heal despite open reduction internal fixation of the ulna, a bipolar radial head replacement, and cross pinning of the distal radioulnar joint. This case demonstrates that failure of the interosseous membrane can occur even in a properly replaced bipolar radial head with adequate immobilization of the forearm and pinning of the distal radioulnar joint.

Solitary intra-articular osteochondroma of the finger.

BACKGROUND: A solitary osteochondroma of the finger occasionally occurs intra-articularly and may cause clinical symptoms, including limited motion and deformity. The present report describes the clinical features and the results of operative treatment for a series of patients who had a solitary intra-articular osteochondroma of the finger. METHODS: Ten patients with a solitary intra-articular osteochondroma of a phalanx of a finger were managed surgically. Eight patients were male, and two were female. The average age at the time of surgery was fourteen years. Treatment consisted of mass excision for three patients and mass excision with corrective osteotomy for six. One additional patient had a boutonniere deformity and underwent extensor tendon reconstruction combined with mass excision. The average duration of follow-up was forty-four months. RESULTS: The proximal phalanx was affected in six patients, and the middle phalanx was affected in four. All tumors involved the distal epiphysis. All patients had postoperative improvement in terms of deformity and/or limitation of motion. Six patients had a preoperative mean coronal plane deformity of 29 degrees, which improved to 4 degrees after surgery. The preoperative mean arc of flexion-extension improved from 54 degrees to 78 degrees in four patients who had a motion deficit at the proximal interphalangeal joint and from 60 degrees to 80 degrees in one patient who had a motion deficit at the distal interphalangeal joint. Two patients had a residual flexion contracture, one with preexisting osteoarthritis and one with a longstanding progressive boutonniere deformity. There were no other complications or recurrences. CONCLUSIONS: Isolated intra-articular osteochondroma of the finger can cause deformity and/or motion limitation. Early mass excision and corrective osteotomy when indicated are recommended to restore full range of motion and to prevent osteoarthritis and secondary deformity.

Bone invasion by squamous cell carcinoma in situ (Bowen's disease) of the finger during treatment with imiquimod 5% cream: case report.

Imiquimod 5% cream is known as an alternative treatment option for squamous cell carcinoma in situ (SCCIS), frequently termed Bowen's disease. Although imiquimod cream has been reported by many authors to treat SCCIS successfully, its efficacy and safety have not been fully established. The authors experienced a case in which ray amputation was necessary because of bone invasion by SCCIS in a finger being treated with imiquimod cream.

Delayed-onset ulnar neuropathy at the wrist associated with distal radioulnar joint arthritis after radius malunion: report of two cases.

Although ulnar neuropathy can occur at the wrist in association with distal radius fractures, few late-onset cases have been reported. The authors describe 2 cases of delayed-onset ulnar neuropathy at the wrist, which developed 12 and 30 years after sustaining a conservatively treated distal radius fracture. During late neurolysis, both patients were found to have a perforation in the volar wrist capsule and synovitis and arthritis in the distal radioulnar joint.

Functional outcomes after upper extremity surgery for cerebral palsy: comparison of high and low manual ability classification system levels.

PURPOSE: The heterogeneity of cerebral palsy makes interpretation and prediction of outcome after upper extremity surgery difficult. We hypothesized that the outcome of upper extremity surgery for cerebral palsy is related to the Manual Ability Classification System (MACS) level. METHODS: We reviewed 27 patients with a mean age of 22 years, who underwent upper extremity surgery for spastic cerebral palsy at a mean follow-up of 29 months. Patients were classified into 5 MACS levels using a standardized questionnaire completed by their primary caregivers. Preoperatively and at most recent follow-up visits, patients were assessed using the House scale and patient-reported functional outcomes on a 5-point scale. We compared the outcomes of patients with high (I-II, independence in daily activities) and low (III-V, dependence in daily activities) MACS levels. RESULTS: The overall mean House scale improved from 2.9 to 4.6 postoperatively (p<.001), dressing ability from 3.7 to 4.2 (p=.005), hygiene from 4.2 to 4.9 (p=.005), and appearance from 2.4 to 4.2 (p<.001). A total of 13 patients had a high MACS level (7 had I and 6 had II) and 14 had a low MACS level (8 had III, 6 had IV, and none had V). The high-MACS group had a greater improvement according to the House scale (p=.009) and the low-MACS group had a larger improvement in hygiene status (p=.043). There were no differences in the amount of improvement in dressing ability (p=.169) and appearance (p=.765). Overall satisfaction with surgery was higher for the high-MACS group (p=.038). CONCLUSIONS: The high-MACS group had a greater improvement in rating according to the House scale and higher satisfaction than the low-MACS group after upper extremity surgery for cerebral palsy in our small number of patients. This study suggests that the MACS level can be used to predict upper extremity surgery outcomes for cerebral palsy. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Lateral calcaneal artery adipofascial flap for reconstruction of the posterior heel of the foot.

BACKGROUND: Soft tissue defects of the posterior heel of the foot present difficult reconstructive problems. This paper reports the authors' early experience of five patients treated with a lateral calcaneal artery adipofascial flap. METHODS: Between 2003 and 2007, five patients (3 males and 2 females) with soft-tissue defects over the posterior heel underwent a reconstruction using a lateral calcaneal artery adipofascial flap and a full-thickness skin graft. The flap sizes ranged from 3.5 x 2.5 cm to 5.5 x 4.0 cm. RESULTS: All five flaps survived completely with no subsequent breakdown of the grafted skin, even after regularly wearing normal shoes. The adipofascial flap donor sites were closed primarily in all patients. CONCLUSIONS: Lateral calcaneal artery adipofascial flaps should be included in the surgical armamentarium to cover difficult wounds of the posterior heel of the foot. These flaps do not require the sacrifice of a major artery to the leg or foot, they are relatively thin with minimal morbidity at the donor site, and leave a simple linear scar over the lateral aspect of the foot.

Contribution of the proximal nerve stump in end-to-side nerve repair: in a rat model.

BACKGROUND: The aim of this study was to evaluate the contribution of the proximal nerve stump, in end-to-side nerve repair, to functional recovery, by modifying the classic end-to-side neurorrhaphy and suturing the proximal nerve stump to a donor nerve in a rat model of a severed median nerve. METHODS: Three experimental groups were studied: a modified end-to-side neurorrhaphy with suturing of the proximal nerve stump (double end-to-side neurorrhaphy, Group I), a classic end-to-side neurorrhaphy (Group II) and a control group without neurorrhaphy (Group III). Twenty weeks after surgery, grasping testing, muscle contractility testing, and histological studies were performed. RESULTS: The grasping strength, muscle contraction force and nerve fiber count were significantly higher in group I than in group II, and there was no evidence of nerve recovery in group III. CONCLUSIONS: The contribution from the proximal nerve stump in double end-to-side nerve repair might improve axonal sprouting from the donor nerve and help achieve a better functional recovery in an end-to-side coaptation model.

Patients with wrist fractures are less likely to be evaluated and managed for osteoporosis.

BACKGROUND: Although osteoporosis is being evaluated and treated increasingly in elderly patients with fragility fractures, some studies have suggested that physicians may be missing important opportunities, especially in patients with nonvertebral fractures. The purpose of the present study was to determine whether specialists responsible for treating fractures at various locations have different propensities for evaluating and treating osteoporosis after a fracture in female patients over the age of fifty years. METHODS: A retrospective nationwide cohort study was performed with use of data collected during 2007 by the Korean Health Insurance Review Agency, which covers 97% of the population. The incidences of fractures around the hip, spine, and wrist in female patients more than fifty years of age and the frequencies of bone density scans for osteoporosis and the use of medications for its treatment were analyzed and compared. RESULTS: The database identified 31,540 hip fractures, 58,291 spine fractures, and 61,234 wrist fractures in female patients who were more than fifty years of age in Korea during 2007. Of these patients, 7095 (22.5%) with a hip fracture, 16,779 (28.8%) with a spine fracture, and 5348 (8.7%) with a wrist fracture underwent diagnostic bone density scans. Furthermore, 7060 patients (22.4%) with a hip fracture, 17,551 (30.1%) with a spine fracture, and 4594 (7.5%) with a wrist fracture were managed with at least one medication approved for the treatment of osteoporosis. CONCLUSIONS: Despite a recent increase in the recognition of osteoporosis in patients with fragility fractures, our review of this national cohort indicates that patients with a wrist fracture are less likely to be evaluated and managed for osteoporosis than those with a hip or spine fracture by physicians who are responsible for treating symptomatic fractures. Additional studies and intervention programs are necessary to improve this care gap, beginning with physicians who are responsible for fracture treatment.