Citations

The use of arthroscopy of the hand and wrist has recently increased sharply in the elective setting and this, not surprisingly, has been followed by an increasing use in the trauma setting. Advocates for the use of arthroscopy in these patients cite the improved assessment of the displacement and reduction of fractures and the early diagnosis of associated injuries, while others temper this with concerns about increased operating time and possible complications. The data relating to patient-reported benefits and costs are limited. The aim of this review was to discuss the current available literature for the use of arthroscopy in the management of injuries of the hand and wrist.Cite this article: Bone Joint J 2025;107-B(3):291–295.

Background: The purpose of this study was to report our long-term outcomes following reconstruction of the forearm interosseous membrane (IOM) with bone-patellar tendon-bone (BPTB) graft for treatment of chronic Essex-Lopresti injuries. Methods: We identified 33 patients who underwent IOM reconstruction with BPTB graft for chronic Essex-Lopresti injuries over a 20-year treatment interval. Twenty male and 13 female patients, with a mean age of 42.1 years (range, 19 to 73 years) and a minimum follow-up interval of 5 years, were included. Preinjury clinical examination and radiographic measurements were obtained from records for comparison with prospectively collected data. Additional functional outcome data collected postoperatively included QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH]), modified Mayo wrist (MMW), and Broberg-Morrey elbow function scores. Results: IOM reconstruction was performed at a mean interval (and standard deviation) of 44.9 ± 60.0 months (range, 6.4 to 208 months) from the time of the initial injury. At a mean follow-up of 10.9 ± 4.4 years (range, 5.5 to 24.2 years), significant improvements were observed in mean elbow flexion-extension arc (+13° [95% confidence interval (CI), 4° to 22°]; p = 0.005), wrist flexion-extension arc (+19° [95% CI, 4° to 34°]; p = 0.016), forearm pronation-supination (+23° [95% CI, 8° to 39°]; p = 0.004), and grip strength (+25% of that of the contralateral side [95% CI, 18% to 32% of contralateral side]; p < 0.001). Improvements in ulnar variance were sustained over the long term from +3.9 mm (95% CI, 3.2 to 4.6 mm) preoperatively to −1.6 mm (95% CI, −2.3 to −0.9 mm) immediately postoperatively and −1.1 mm (95% CI, −1.8 to −0.4 mm) at the time of the final follow-up (p < 0.001). The mean QuickDASH, MMW, and Broberg-Morrey scores were 29.8 (range, 5 to 61), 82.7 (range, 60 to 100), and 91.6 (range, 64 to 100), respectively. Conclusions: IOM reconstruction with a BPTB graft is an effective treatment option for chronic Essex-Lopresti injuries, with satisfactory clinical and functional outcomes over the long term. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Fractures of the olecranon are sometimes difficult to treat. The steps for operative plate fixation of olecranon fractures consist of (1) a dorsal incision, (2) exposure using full-thickness flaps, (3) removal of hematoma from the fracture site, (4) fracture reduction, (5) provisional fixation, (6) plate application, (7) proximal fixation, (8) distal fixation, and (9) layered wound closure. Although this is generally a straightforward procedure, several specific steps may make fixation easier and improve outcomes. Outcomes following olecranon fracture fixation are generally good. Patients should expect some loss of terminal extension and a potential for symptoms related to implant prominence, especially in slender patients. Ulnar nerve symptoms are unusual but possible.

Radial head fractures may commonly be treated by (1) open reduction and internal fixation (ORIF), (2) radial head excision, or (3) radial head replacement. If there is no associated elbow instability with lateral ulnar collateral ligament (LUCL) injury, the preferred approach is via a split in the extensor digitorum communis (EDC) origin. This provides a wide exposure but limits the risk of injury to the LUCL and associated instability. The radial head is fixed, excised, or replaced. Open treatment of radial head fractures begins with the following steps: (1) a laterally based incision is centered over the radiocapitellar joint, (2) the EDC is split at the midline of the radial head and elevated off the bone anteriorly and superiorly, and dissection proceeds distally, splitting the extensor origin along its fibers, and (3) the capsule is opened and the radial head fracture, identified. For ORIF, provisional fixation is then obtained with Kirschner wires and small bone reduction clamps. Headless low-profile screws are preferred if possible. If a plate is used, the dissection proceeds distally and the posterior interosseous nerve may need to be identified and protected. Definitive fixation is applied in the safe zone for implant placement (i.e., a right angle based laterally when the forearm is in a neutral position). For excision of the radial head as definitive treatment or for radial head replacement, the fragments are removed and an oscillating saw is used to remove additional radial neck or other fragments. When radial head excision is the definitive treatment, the radial neck is planed to a smooth contour that allows for placement of the prosthesis or for smooth motion without impingement at the proximal radioulnar joint. An indication for radial head replacement is suspicion of an Essex-Lopresti-type injury or demonstration of longitudinal instability of the forearm with excessive motion when a “push-pull” test is performed under fluoroscopy of the wrist while traction is applied to the radial neck. The final step of open treatment of radial head fractures, before the wound is closed in layers, consists of assessment of the range of motion and use of fluoroscopy to confirm appropriate fixation, resection, or prosthetic position. Outcomes following radial head fixation, resection, or arthroplasty for isolated radial head fractures are generally favorable. Loss of motion is particularly problematic in the pronation-supination arc in the setting of plate fixation, and patients are generally counseled that implant removal is often necessary. Loss of motion in the flexion-extension arc, particularly loss of terminal extension, may be noted. Resection of the radial head results in radiographic evidence of degenerative changes along the ulnohumeral joint, but this may be well tolerated as symptoms develop slowly, particularly in older patients. Radial head replacement results in changes in the capitellum over time, but these are usually asymptomatic.

Background We report on the non-operative treatment of Mayo Type II olecranon fractures. Methods Fourteen isolated Mayo Type II olecranon fractures were treated non-operatively, followed to discharge, and retrospectively reviewed. Treatment was splinting in extension followed by protected active motion beginning 3 weeks to 4 weeks post-injury. Mayo Elbow Performance Index (MEPI) and Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were available in 86% and 64% of cases, respectively. Follow-up radiographs were obtained. Results At discharge, the mean (SD) MEPI score was 95 (5). The mean (SD) elbow motion arc was 121° (21°). One patient re-fractured his elbow after discharge by falling on the ice. He recovered after open reduction and internal fixation. One patient (documented Marfan syndrome) developed an asymptomatic non-union. Excepting the patient who fell, no patient received additional care. Conclusions In this pilot report, Mayo Type II olecranon fractures were treated non-operatively to discharge. Good to excellent results were obtained in all patients according to the MEPI. Supportive care of these fractures should be comparatively studied. A downside risk to providing supportive care for these fractures was not identified.

Background: Therapy programs to treat thumb carpometacarpal (CMC) arthritis may engage selective activation and reeducation of thenar muscles, particularly the first dorsal interosseous (FDI) and opponens pollicis (OP) to reduce subluxation of the joint. We describe the effect of simulated selective activation of the FDI and OP muscles upon radiographic subluxation of the thumb CMC joint. Methods: In a cadaver model of CMC subluxation, loads were applied to the FDI, the OP, and then concomitantly at 0%, 25%, 50%, 75%, and 100% maximal loads and radial subluxation of the joint and reduction in subluxation was measured. Results: Selective activation of the OP, alone, improved the subluxation ratio (SR) in a dose-dependent manner. Selective activation of FDI, alone, demonstrated minimal effects on SR. Concomitant activation of OP and FDI improved the SR across all loading states, and activation of 75% and greater, when compared with FDI activation alone, resulted in a statistically significant improvement in SR to within 10% of the presubluxed joint. Conclusions: Concomitant activation of the FDI and OP acts to reduce subluxation of the thumb CMC joint in a dose-dependent fashion. The OP is likely the predominant reducing force. Hand therapy programs that focus on selective strengthening programs likely function in part to encourage patients to activate the easily palpable and easily understood FDI. Concomitant coactivation of the OP may be the major reducing force to elicit clinical and radiographic reduction of subluxation, improved thumb positioning, and reduction of pain and arthritic symptoms.

Background: This study investigated whether axillary nerve (AN) distance to the inferior border of the humeral head and inferior glenoid would change while placing the glenohumeral joint in different degrees of external rotation and abduction. Methods: A standard deltopectoral approach was performed on 10 fresh-frozen cadaveric specimens. The distance between AN and the inferior border of the humeral head and inferior glenoid while placing the shoulder in 0°, 45°, and 90° of external rotation or abduction was measured. Continuous variables for changes in AN position were compared with paired 2-tailed Student t test. Results: The mean distance between the AN and the humeral head with the shoulder in 0°, 45°, and 90° of external rotation and 0° of abduction was 13.77 mm (SD 4.31), 13.99 mm (SD 4.12), and 16.28 mm (SD 5.40), respectively. The mean distance between the AN and glenoid with the shoulder in 0°, 45°, and 90° of external rotation was 16.33 mm (SD 3.60), 15.60 mm (SD 4.19), and 16.43 (SD 5.35), respectively. The mean distance between the AN and the humeral head with the shoulder in 0°, 45°, and 90° of abduction and 0° of external rotation was 13.76 mm (SD 4.31), 10.68 mm (SD 4.19), and 3.81 mm (SD 3.08), respectively. The mean distance between the AN and glenoid with the shoulder in 0°, 45°, and 90° of abduction was 16.33 mm (SD 3.60), 17.66 mm (SD 5.80), and 12.44 mm (SD 5.57), respectively. Conclusions: The AN position relative to the inferior aspect of the glenohumeral joint does not significantly change despite position of external rotation. Increasing shoulder abduction over 45° decreases the distance from the glenohumeral joint to the AN and should be avoided.

Objective: Symptomatic thumb carpometacarpal (CMC) joint osteoarthritis is common. Early data support selective strengthening of the first dorsal interosseous (FDI) and opponens pollicis (OP) muscles for conservative management with improvement in pain and functional outcomes scores. There are limited biomechanical studies to support such strengthening programs. The purpose of these studies was to quantify the kinematics and joint kinetics at the thumb CMC joint during simulated pinch with selective activation of the FDI and OP muscles. The first study was completed with all ligamentous attachments of the CMC joint intact. The second study was completed with all CMC ligaments released. Hypothesis: Our hypothesis was that increased loads in the FDI and OP result in effects to the joint kinematics and reduce subluxation. Results: Our results from both studies show the OP and FDI act synergistically to center the first metacarpal on the trapezium and reduce subluxation during simulated pinch. The OP is the predominant corrective force but tends to overcorrect if unopposed. The FDI tempers the action of OP and contributes to improved CMC congruency. Conclusion: Our conclusion is these biomechanical data support selective thenar muscle re-education and strengthening programs for conservative management of thumb CMC joint osteoarthritis and pain.

Abstract Osteochondritis dissecans (OCD) of the humeral capitellum most commonly affects young athletes engaged in sports that repetitively stress the elbow. It is characterized by localized injury of subchondral bone of the humeral capitellum. To determine the best treatment option for OCD in young athletes, it is important to differentiate between stable and unstable OCD lesions. Stable lesions can be treated with rest, whereas unstable lesions, as well stable lesions that do not respond to conservative therapy, may require a surgical approach. Magnetic resonance imaging is the diagnostic study of choice to evaluate capitellar OCD lesions and loose bodies and to accurately determine the stability and viability of the OCD fragment. A variety of surgical approaches have been reported, from internal fixation of large fragments to autologous chondrocyte grafts. Arthroscopic surgery is becoming the standard treatment of capitellar OCD. This minimally invasive approach shows good results, a low risk of operative morbidity, and early recuperation postoperatively. The distal ulnar portal we describe here allows for ergonomic exposure to the posterolateral capitellum, providing easier access for drilling, burring, and local debridement of lesions amenable to arthroscopy.