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Bones and Joints

Hand & wrist bone/joint pathology: fractures, congenital anomalies, and degenerative conditions—diagnostic & surgical approaches.

Overview

Surgical management of hand and wrist osteoarthritis, including fusion or arthroplasty, is selected based on the specific joint involved, patient demands, and complication risks [1]. Appropriate use of arthroplasty and arthrodesis requires careful consideration of patient needs [3]. Arthroplasty generally provides good pain relief but carries high rates of deformity recurrence and complications depending on the implant type and joint involved [13]. Scaphoid silicone arthroplasty indications should be limited because residual pain and spacer subluxation often lead to secondary reconstructive and salvage procedures [23].

In pediatric upper extremity bone lengthening, success is commonly defined by radiographic lengthening, joint motion, and patient satisfaction rather than validated outcome measures [4]. This procedure is associated with a high complication rate [4]. For chronic scapholunate Geissler 3C lesions, modified Viegas capsuloplasty represents a safe and effective joint-preserving surgical option in appropriately selected patients [14]. Functional range of motion of finger joints is important for directing indications for surgery and rehabilitation, and assessing outcome of treatment [15].

For elbow fracture-dislocations, the goal of surgical fixation is a stable reduced joint that will tolerate immediate postoperative range of motion [59]. Metallic hinged prostheses have been used to restore function in rheumatoid finger joints, with indications including gross joint destruction, dislocation, and persistent deformity [61]. Tenolysis in the hand and wrist is unsuccessful when done in the face of poor indications, when the tendon is not freed completely, or when performed in association with complex orthopaedic procedures which do not permit early postoperative active motion [67].

Intraoperative assessment of articular surfaces is recommended over preoperative radiographs for selecting between proximal row carpectomy and scaphoid excision with intercarpal arthrodesis [18]. The one-bone forearm reconstructive procedure is indicated only if instability and bone loss are irreparable by bone-grafting or other reconstructive procedures and there is no chance of restoring rotation of the forearm [20].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Forearm rotation kinematics are precisely characterized using four-dimensional computed tomography [31]. Forearm positioning significantly influences daily functioning, strength, and skilled hand use [66]. Mean forearm shortening of 3 or 4 cm results in near-complete loss of flexor digitorum profundus (FDP) simulated muscle force and tip-to-palm force in wrist-neutral and wrist-extension positions, respectively [74].

The metacarpophalangeal joint possesses five kinematic degrees of freedom from a mechanical perspective [42]. Three-dimensional analysis of internal forces in thumb joints during pinch and grasp elucidates tensile forces in functioning tendons, contact and shear forces, and constraining moments acting on the joints [51, 52]. Video motion capture identifies three movement phases of the hand during lateral and pulp pinches, providing insight into hand movement dynamics and a basis for evaluating movement patterns in activities of daily living [60].

Wrist biomechanics are significantly altered following trapeziectomy, with ligamentous reconstruction and tenodesis (LRTI) most closely resembling intact biomechanics in cadaveric models [45]. Lunate morphology affects the three-dimensional kinematics of the carpus during wrist flexion and extension [53]. Distal radius fractures interfere with the biomechanical integrity of the wrist, limiting range of motion and affecting hand muscle strength [55]. Incongruous radiocarpal joints are well tolerated due to wrist biomechanics, particularly the role of the midcarpal joint in dart-throwing motion, questioning the necessity of aggressive treatment for stepoffs larger than 1 mm [82]. New perspectives on carpal mechanics are highlighted as topics receiving disproportionately less attention relative to their clinical relevance [54].

Soft Tissue and Neurological Considerations

A thorough understanding of biomechanical principles and neurological pathways is necessary for hand surgeons managing upper limb spasticity [33]. Effective surgery restores biomechanical motions so patients have optimum use, requiring digits to have sensation and freedom of motion [63]. Finger forces are more hampered while gripping objects with smaller circumferences than large ones following flexor digitorum superficialis tendon transfer [57]. Thumb extension and abduction functions can be reconstructed using extensor pollicis brevis tendon transfer without requiring a pulley [73].

Fracture Management and Measurement

Both plate and intramedullary screw fixation for extra-articular metacarpal base fractures surpass expected physiologic loading during hand use, making either approach biomechanically acceptable depending on clinical context [40]. Understanding foundational principles of anatomy and kinematics and initiating early mobilization are critical components in the treatment algorithm for fractures of the carpus and hand [79]. Limitations in quantifying joint motion to exact precision persist even with in-person assessment [72]. The inter-metacarpal distance method is currently the most reliable tool for measuring thumb carpometacarpal palmar and radial abduction in adults with thumb carpometacarpal joint pain [75].

Classification

Trapeziometacarpal Joint: Radiological classification of trapeziometacarpal joint osteoarthritis does not accurately describe all stages, preventing reliable and consistent communication between clinicians [8]. Various radiological measurements and classifications are used to evaluate the trapeziometacarpal joint [17].

Forearm Disorders: There is a lack of a generally accepted classification system for chronic skeletal disorders of the forearm in adults [11].

Hand Fractures (AO): The adapted AO classification for hand fractures demonstrates good inter-observer agreement for bone identification [46]. The adapted AO classification for hand fractures demonstrates substantial agreement for bone segment coding [46]. The adapted AO classification for hand fractures demonstrates moderate agreement for fracture type [46].

Synpolydactyly: A new, reliable radiographic classification system for synpolydactyly of the hand has been presented to improve clinician communication and serve as a foundation for future investigations [48].

Hamatometacarpal Fracture-Dislocation: A novel classification system for hamatometacarpal fracture-dislocation based on CT scan can be used to establish guidelines for appropriate treatment [50].

Distal Radial Fractures (Buttazzoni): The Buttazzoni classification system for distal radial fractures in adults is simple, covers all radial fracture types, and has acceptable reliability comparable to commonly used systems [58].

Congenital Anomalies (ObergeManskeeTonkin): The ObergeManskeeTonkin classification system is recommended to replace the Swanson classification for congenital anomalies of the hand and upper limb due to increased knowledge of molecular etiology and the need for a system that describes the limb axis and specific anomalies [62].

Coronoid Process Fractures: The proposed radiographic classification for coronoid process fractures of the ulna has prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures [65].

Türker Classification: An additional category (Type 3) is proposed for the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual [70].

Extensor Pollicis Longus: A classification system for anomalies of the extensor pollicis longus is proposed to organize variations of the long extensor tendon to the thumb and help avoid confusion during surgeries involving repair or transfer of these tendons [81].

Other Considerations: Different classification systems for upper limb orthoses have been developed with various aims [80].

Clinical Presentation

Acute Injury and Trauma

Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [39]. In athletes, the diagnosis of finger metacarpophalangeal joint injuries begins with an understanding of all potential diagnoses [34]. For toe extensor tendon anatomy issues, prompt and adequate management prevents joint stiffness and loss of function [37].

Chronic Arthropathy and Degenerative Conditions

Surgical options for osteoarthritis of the hand and wrist, such as fusion or arthroplasty, are selected based on the specific joint involved, patient demands, and the risk of complications [1]. Appropriate use of arthroplasty and arthrodesis for affected joints in rheumatoid and osteoarthritic hands and wrists requires careful consideration of the patient's needs [3]. The diagnosis of thumb arthritis involves reviewing pathoanatomy, physical examination, and imaging options [30]. Initial management of symptomatic distal radioulnar joint (DRUJ) arthritis is nonsurgical, with surgery reserved for patients with refractory pain [12]. Disorders of the distal radioulnar joint are a common source of ulnar-sided wrist pain [41].

Diagnostic Challenges and Imaging

Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain [6]. In patients with musculoskeletal syndromes presenting with wrist pain, it is important to carefully examine both wrists and evaluate radiographic studies to determine if carpal anomalies may be contributing to their pain [38]. Objective radiographic data may aid in preliminary diagnosis and treatment recommendations for metacarpal features in Blauth Type III thumb hypoplasia, although in-person physical examination remains necessary [7]. Diagnosis of congenital absence of the flexor pollicis longus tendon without associated thumb hypoplasia anomalies can be confirmed using physical examination, direct radiography, and magnetic resonance imaging [10].

A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis [2]. Differentiating tenosynovitis with psammomatous calcification from intra-articular lesions is important, particularly in atypical presentations [43]. Diagnosis of bizarre parosteal osteochondromatous proliferation (Nora lesion) in pediatric phalanges can be challenging due to presenting symptoms and radiographic findings [35]. Osteoid osteoma should be considered in the differential diagnosis for painful bony tumors in the hand, particularly in pediatric and adult patients, as it can present with atypical features and locations making work-up and diagnosis challenging [36]. Prompt diagnosis and surgical excision of osteoid osteoma of the scaphoid may prevent irreversible articular damage [9].

Systemic and Complex Disorders

Chronic skeletal disorders of the forearm in adults involve both bone and soft-tissue structures, contributing to treatment complexity and a lack of a generally accepted classification system [11]. When elbow pain is accompanied by musculoskeletal or systemic red flags, clinicians should perform a structured assessment and refer promptly [32].

Investigations

Plain radiography: Plain radiography provides the most basic and useful information for shoulder diagnostic imaging [77]. For hand tumors, radiographs are mandatory components of the initial imaging work-up [110]. In patients with nonspecific wrist pain, clinicians should be careful ascribing symptoms to anatomical variations on radiographs [6]. The radiological classification of carpometacarpal joint osteoarthritis does not describe all stages accurately enough to permit reliable and consistent communication between clinicians [8]. Objective radiographic data may aid in preliminary diagnosis and treatment recommendations for Blauth Type III thumb hypoplasia, although in-person physical examination remains necessary [7]. Delayed diagnosis of carpometacarpal fracture-dislocations makes closed reduction difficult and is associated with less favorable radiographic outcomes [27]. Standard radiographs provide between 53% and 90% sensitivity for hook of hamate fractures [106]. Radiological findings support good bone tolerance with signs of progressive integration for spherical pyrocarbon HAPY metacarpophalangeal interposition arthroplasty, despite moderate erosion and bone remodeling in some cases [97]. Early radiographic results of triquetral autograft reconstruction of the lunate fossa of the distal radius are promising [105].

MRI: MRI provides the most information about soft tissues in shoulder diagnostic imaging [77]. Diagnosis of congenital absence of the flexor pollicis longus tendon can be confirmed using physical examination, direct radiography, and magnetic resonance imaging [10]. MRI alters the treatment of hand, wrist, and elbow conditions in less than 1 in 5 patients [99]. Vascularized bone graft is recommended for scaphoid nonunion when osteonecrosis of the proximal pole is evident on MRI [102]. MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers [108]. Patients with juxta-articular myxoma of the thumb remained pain- and symptom-free at 14 months with full range of motion and no recurrence on MRI [109]. For hand tumors, MRI should be requested for atypical findings such as bone extension of a soft tissue lesion, osteolysis, or size greater than 3 cm [110].

CT: Radiographs, CT, and MRI all demonstrate excellent inter-rater agreement with no significant difference in bias from true ulnar variance when compared to each other [88]. CT offers 94% specificity and 97% accuracy for hook of hamate fractures [106]. Advanced imaging, including standard CT, is helpful to confirm the diagnosis of thumb metacarpal-trapezoid impingement after trapeziectomy and basal joint soft tissue arthroplasty [101].

Other Considerations: Surgical options for hand and wrist osteoarthritis, such as fusion or arthroplasty, are selected based on the specific joint involved, patient demands, and the risk of complications [1]. A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis [2]. Advanced imaging, including bone scintigraphy and single-photon emission CT, is helpful to confirm the diagnosis of thumb metacarpal-trapezoid impingement after trapeziectomy and basal joint soft tissue arthroplasty [101].

Treatment

Non-Operative Management

Initial management of symptomatic distal radioulnar joint (DRUJ) arthritis is nonsurgical, with surgery reserved for patients with refractory pain [12]. Nonoperative therapy is recommended as the initial treatment course for scaphotrapezio-trapezoid arthritis [68] and is commonly used as first-line treatment for tenosynovitis of the hand and wrist [95]. Conservative treatment serves as the initial approach for Extensor Indicis Proprius Syndrome, though surgical decompression is indicated if conservative measures fail [94]. Management of vascular anomalies of the hand and wrist involves initial conservative therapy followed by interventional options or surgery for persistent pain, swelling, or functional impairment [96].

Thumb carpometacarpal (CMC) joint arthritis is an expected part of aging, and many patients may become asymptomatic or minimally symptomatic; therefore, nonoperative care including therapy should be offered as first-line treatment as patients may find relief and never proceed with surgery [100]. Habitual dislocation of the thumb metacarpophalangeal joint in children should be managed conservatively by resisting surgical attempts to tighten the joint and encouraging children to unlearn the habit [64]. Conservative management resulted in a satisfactory short-term outcome for an elderly, low-demand patient with minimal symptoms and posttraumatic ulnar translocation of the carpus [103].

Operative Management

Indications: Surgical options such as fusion or arthroplasty are selected based on the specific joint involved, patient demands, and the risk of complications [1]. Appropriate use of arthroplasty and arthrodesis for affected joints requires careful consideration of the patient's needs [3]. Treatment of the arthritic wrist requires a diversity of treatment options due to the complex integrated system of joints, rather than a single effective treatment [47]. The functional range of motion is important for directing indications for surgery and rehabilitation, and assessing outcome of treatment [15]. Surgical treatment targets treating joint imbalance to prevent fixed deformity [71].

Surgical Approach / Technique: The one-bone forearm procedure is indicated only if instability and bone loss are irreparable by bone-grafting or other reconstructive procedures and there is no chance of restoring rotation of the forearm [20]. Proximal row carpectomy versus scaphoid excision and intercarpal arthrodesis selection should be based on intraoperative assessment of articular surfaces rather than preoperative radiographs [18]. Retrograde drilling is a safe and reasonable treatment option to stimulate healing of the subchondral bone in capitellar osteochondritis dissecans without disruption of the articular cartilage [49]. Fixation for condylar fractures of the proximal and middle phalanges is possible up to 8 weeks after injury, though earlier treatment yields better range of motion outcomes [69]. Vascularized bone graft based on the ulnar artery is advocated for complex recalcitrant scaphoid non-unions where conventional grafts may fail due to poor vascularity [104]. Modified Viegas capsuloplasty for chronic scapholunate Geissler 3C lesions represents a safe and effective joint-preserving surgical option in appropriately selected patients [14]. Management principles for hypertrophic non-union of a pathological forearm fracture secondary to multiple myeloma include stabilization of the entire bone and early mobilization [90].

Implant Selection: Arthroplasty in the hand provides generally good pain relief but has high rates of deformity recurrence and complications depending on the implant type and joint involved [13]. Scaphoid silicone arthroplasty indications should be limited, as residual pain and spacer subluxation often lead to secondary reconstructive and salvage procedures [23]. Recent small series have suggested a satisfactory rate of acceptable outcomes for arthroscopic evaluation and treatment of basilar joint arthritis [44]. A systematic review provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis, with some interventions showing moderate-to-large superior effects compared with others [56].

Other Considerations: Bone lengthening in the pediatric upper extremity is associated with a high complication rate, and success is commonly defined by radiographic lengthening, joint motion, and patient satisfaction rather than validated outcome measures [4]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [5]. The prognosis for fracture-dislocation of the radiocarpal joint is guarded, with good results in early-treated patients but potential for late post-traumatic arthritis [21]. The prognosis for fractures and dislocations of the base of the thumb metacarpal depends on the quality of the restoration of the mobility of the trapeziometacarpal joint [22]. The best management for trapeziometacarpal arthritis remains debated, with a constant proportion of patients remaining unhappy or symptomatic post-surgery despite 70 years of research and numerous treatment options [93].

Complications

Joint Degeneration and Arthritis: Joint chondrolysis requires standardized clinical criteria to guide differential diagnosis [2]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [5]. The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis [85]. Long-term outcomes for trapeziometacarpal arthritis-associated metacarpophalangeal hyperextension deformity remain unknown [26].

Bone and Soft Tissue Complications: Bone lengthening in the pediatric upper extremity is associated with a high complication rate [4]. Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after the injury [87]. Mild interphalangeal joint deformity may persist without functional impairment after surgical correction of floating thumb duplication [115]. Prompt diagnosis and surgical excision of osteoid osteoma of the scaphoid may prevent irreversible articular damage [9].

Nerve Injury Management: No adverse events or revisions were reported with the use of processed nerve allografts for nerve injuries greater than 4cm [91]. No adverse events or revisions were reported with the utilization of processed nerve allografts for large gap nerve discontinuities [92].

Infection and Septic Arthritis: Patients requiring arthrodesis or amputation for septic arthritis of small joints of the hand tended to be men in their sixties with comorbidities, an idiopathic cause, and delayed presentation [113].

Other Considerations: Distal radioulnar joint arthroplasty is associated with frequent reoperations [24]. MatOrtho proximal interphalangeal joint arthroplasty had a survival rate of 85% at a minimum of 2-years follow-up [25]. Long-term outcomes for pelvic ring injuries are complicated by posterior pelvic pain and are largely multifactorial [83].

Recovery

Light activity (weeks): Specific timelines for light activity are not defined in the current evidence base. However, early management strategies vary by pathology. For traumatic radiocarpal translocation, long-term follow-up showed no recurrence of translation [86]. In cases of triangular bone dislocation, patients achieved essentially normal range of motion and freedom from pain at thirty-four months follow-up [118].

Full activity (months): Long-term functional outcomes depend heavily on the specific intervention and pathology. For scaphoid non-union, current studies indicate that pyrolytic carbon implant for proximal pole replacement aims to improve long-term functional outcomes [16]. In the context of scaphoid hemi-resection and radiocarpal arthrodesis (SHARC procedure), the remaining motion is functional, pain relief is substantial, and long-term outcomes suggest minimal deterioration despite limitations in total movement degree [84]. For distal radioulnar joint arthroplasty, functional outcomes improved in both implant groups, though reoperations were frequent [24].

Complete recovery / outcome plateau (months): Prognosis and final outcomes vary significantly by condition. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [5]. Few of the forty-seven scaphoid non-unions were undisplaced, stable, or free of arthritis after ten years [29]. Conversely, the articular surface of the scaphoid remodels over time in skeletally mature subjects, with normal architecture completely restored by 3 years [116]. For radiocarpal fracture-dislocations, the prognosis is guarded; while early-treated patients achieve good results, there is potential for late post-traumatic arthritis [21]. In congenital bilateral pseudarthrosis of the index metacarpal bones, union was achieved in a relatively short period with nonvascularised bone graft [117].

Rehabilitation protocol: Rehabilitation strategies are tailored to the specific deformity or procedure. For Madelung's deformity, reverse wedge osteotomy of the distal radius is performed with the hope that flattening the dorsal aspect of the wrist provides long-term protection against extensor tendon tear [19]. In trapezial-metacarpal arthritis associated with metacarpophalangeal hyperextension deformity, volar capsulodesis is recommended to preserve motion, although long-term outcomes remain unknown [26]. For locking little finger caused by a cartilaginous ridge, surgical removal restores normal joint motion [119].

Functional milestones: Functional success is measured by joint stability, pain relief, and radiographic congruity. The prognosis for fractures and dislocations of the base of the thumb metacarpal depends on the quality of the restoration of trapeziometacarpal joint mobility [22]. Delayed diagnosis of carpometacarpal fracture-dislocations makes closed reduction difficult and is associated with less favorable radiographic outcomes [27]. In multiple carpometacarpal dislocations, degenerative changes may occur but do not necessarily result in disabling symptoms at follow-up [120]. Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis likely leads to progression of joint degeneration; recognizing this incongruity allows for measures that may prevent or delay progression [121]. For rheumatoid thumb, soft tissue reconstructions alone are unlikely to correct deformity adequately or maintain correction long-term, making joint procedures preferred [89].

Other Considerations: Long-term treatment plans for radial longitudinal deficiency are guided by the overall health of the child and the severity of deformities, aiming to realign the forearm, wrist, and hand while providing a functional thumb [98]. The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up [25].

Key Evidence

  • [L5] Surgical options such as fusion or arthroplasty are selected based on the specific joint involved, patient demands, and the risk of complications. (10.1016/j.jht.2022.01.001)
  • [L4] A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis. (10.1016/j.arthro.2011.03.025)
  • [L5] Appropriate use of arthroplasty and arthrodesis for affected joints requires careful consideration of the patient's needs. (10.1016/j.hcl.2010.09.003)
  • [L5] The procedure is associated with a high complication rate, and success is commonly defined by radiographic lengthening, joint motion, and patient satisfaction rather than validated outcome measures. (10.2106/jbjs.16.00007)
  • [L4] Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop. (10.2106/00004623-198567030-00013)
  • [L3] Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain. (10.1016/j.jhsa.2017.02.002)
  • [L3] While in-person physical examination remains necessary, objective radiographic data may aid in preliminary diagnosis and treatment recommendations. (10.1016/j.jhsa.2024.04.005)
  • [L3] The radiological classification does not describe all stages of carpometacarpal joint osteoarthritis accurately enough to permit reliable and consistent communication between clinicians. (10.1016/j.jhsa.2014.09.007)
  • [Case_report] Prompt diagnosis and surgical excision may prevent irreversible articular damage. (10.1007/s11552-008-9159-2)
  • [Case_report] Diagnosis can be confirmed using physical examination, direct radiography, and magnetic resonance imaging. (10.1007/s11552-007-9045-3)
  • [L5] Initial management of symptomatic DRUJ arthritis is nonsurgical, with surgery reserved for patients with refractory pain. (10.5435/00124635-201210000-00002)
  • [L4] The review describes various arthroplasty possibilities, indications, and surgical techniques for hand joints, noting that while pain relief is generally good, there are high rates of deformity recurrence and complications depending on the implant type and joint involved. (10.1177/17531934211017703)
  • [L4] It represents a safe and effective joint-preserving surgical option in appropriately selected patients. (10.1177/17531934261454878)
  • [L4] The functional range of motion is important for directing indications for surgery and rehabilitation, and assessing outcome of treatment. (10.1177/1753193414533754)
  • [L4] While long-term research is still required, current studies indicate that the use of this implant can significantly impact on the way scaphoid non-unions are treated, with the goal of improving long term functional outcomes for the person. (10.1016/j.jht.2010.09.015)
  • [L5] This review provides an overview of different radiological views described for the thumb, emphasizing their historical origin and positioning, and describes various measurements and classifications used to evaluate the trapeziometacarpal joint. (10.1177/17531934221137979)
  • [L4] The authors recommend intraoperative assessment of articular surfaces rather than preoperative radiographs for selecting the surgical procedure. (10.1016/j.jhsa.2014.03.032)
  • [Paper] Clinical and radiological results are convincing, with the flattening of the dorsal aspect of the wrist hoped to provide long-term protection against extensor tendon tear. (10.1016/j.otsr.2013.03.007)
  • [L4] Prognosis is guarded, with good results in early-treated patients but potential for late post-traumatic arthritis. (10.2106/00004623-197759020-00011)
  • [L4] The prognosis depends on the quality of the restoration of the mobility of the trapeziometacarpal joint. (10.1177/1753193414554357)
  • [L4] The indications for the procedure should be limited, as residual pain and spacer subluxation often lead to secondary reconstructive and salvage procedures. (10.2106/00004623-198567030-00012)
  • [L4] Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. (10.1016/j.jhsa.2022.02.014)
  • [L4] The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up. (10.1177/1753193415614251)
  • [L5] The author recommends volar capsulodesis to preserve motion, though long-term outcomes remain unknown. (10.1016/j.jhsa.2011.05.006)
  • [L4] Delayed diagnosis makes closed reduction difficult and was associated with less favorable radiographic outcome. (10.1177/1558944719852743)
  • [L4] Few of the forty-seven non-unions were undisplaced, stable, or free of arthritis after ten years. (10.2106/00004623-198466040-00003)
  • [Paper] This issue of Hand Clinics provides a review of the pathoanatomy, physical examination, and imaging options for the diagnosis of thumb arthritis, followed by an exploration of treatment options for early and advanced disease. (10.1016/j.hcl.2008.03.009)
  • [L4] The techniques presented provide a detailed description of forearm kinematics. (10.1177/17531934221142520)
  • [L4] When elbow pain is accompanied by musculoskeletal or systemic red flags, clinicians should perform a structured assessment and refer promptly. (10.1016/j.jht.2026.02.009)
  • [L5] A thorough understanding of biomechanical principles and neurological pathways is necessary for the hand surgeon. (10.1177/17531934261434453)
  • [L5] Accurate diagnosis and treatment of finger metacarpophalangeal joint injuries in athletes begins with an understanding of all potential diagnoses, allowing for safe and early return to play. (10.5435/jaaos-d-21-01031)
  • [L4] The diagnosis in pediatric cases can be challenging due to presenting symptoms and radiographic findings. (10.1016/j.jhsa.2020.05.002)
  • [L4] Osteoid osteoma should be considered in the differential diagnosis for painful bony tumors in the hand, particularly in pediatric and adult patients, as it can present with atypical features and locations making work-up and diagnosis challenging. (10.1016/j.jhsa.2019.01.019)
  • [L4] Prompt and adequate management can prevent joint stiffness and loss of function. (10.1177/1753193420936612)
  • [Case_report] In patients with musculoskeletal syndromes who present with wrist pain, it is important to carefully examine both wrists and evaluate the radiographic studies to determine if carpal anomalies may be contributing to their wrist pain. (10.1007/s11552-010-9304-6)
  • [L5] Both fixation methods surpassed expected physiologic loading during hand use, indicating that either approach may be biomechanically acceptable depending on the clinical context. (10.1016/j.jhsg.2025.100897)
  • [L5] Disorders of the distal radioulnar joint are a common source of ulnar-sided wrist pain, but increased understanding of anatomy and pathology has facilitated accurate diagnosis and successful treatment in most cases. (10.5435/00124635-199503000-00005)
  • [L5] From a mechanical perspective, the metacarpophalangeal joint represents a joint with 5 kinematic degrees of freedom. (10.1016/j.jhsa.2008.10.004)
  • [Case_report] This case highlights the importance of differentiating tenosynovitis with psammomatous calcification from intra-articular lesions, particularly in atypical presentations, and demonstrates the effectiveness of surgical intervention in resolving symptoms. (10.1016/j.jhsg.2023.08.001)
  • [L4] Recent small series have suggested a satisfactory rate of acceptable outcomes for arthroscopic evaluation and treatment of basilar joint arthritis. (10.1016/j.hcl.2011.05.005)
  • [L5] Wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, LRTI most closely resembled the intact biomechanics in this cadaveric model. (10.1016/j.jhsa.2019.10.003)
  • [L4] The adapted AO classification for hand fractures demonstrated good inter-observer agreement for bone identification, substantial agreement for bone segment coding, and moderate agreement for fracture type. (10.1177/1753193409355256)
  • [Paper] Treatment of the arthritic wrist is fascinating and challenging, requiring a diversity of treatment options due to the complex integrated system of joints, rather than a single effective treatment. (10.1016/j.hcl.2005.08.013)
  • [L2] The authors present a new, reliable radiographic classification system for synpolydactyly that will allow improved communication between clinicians and serve as a foundation for future investigations. (10.1177/1753193415598281)
  • [L4] This technique is a safe and reasonable treatment option to stimulate healing of the subchondral bone without disruption of the articular cartilage. (10.1016/j.arthro.2011.03.054)
  • [Paper] The novel classification system for hamatometacarpal fracture-dislocation can be used to establish guidelines for appropriate treatment. (10.1016/j.injury.2012.02.019)
  • [L5] This three-dimensional analysis of the internal forces in the thumb joints during pinch and grasp provides new information concerning the tensile forces in functioning tendons, the contact and shear forces, and the constraining moments acting on the joints. (10.2106/00004623-197759010-00004)
  • [L5] This three-dimensional analysis of the internal forces in the thumb joints during pinch and grasp provides new information concerning the tensile forces in functioning tendons, the contact and shear forces, and the constraining moments acting on the joints. (10.2106/00004623-198769070-00033)
  • [L5] This study describes the effect of lunate morphology on 3-dimensional carpal kinematics during wrist flexion and extension. (10.1016/j.jhsa.2014.09.019)
  • [Paper] This issue of Hand Clinics highlights topics regarding the wrist that have received disproportionately less attention relative to their clinical relevance, including new perspectives on carpal mechanics, nondestructive surgical approaches, and reviews of various diseases and conditions. (10.1016/j.hcl.2006.09.001)
  • [L3] These results supported the initial hypothesis that a fracture of the distal radius interferes with the biomechanical integrity of the wrist, limiting range of motion and affecting hand muscle strength. (10.1177/1758998315574352)
  • [L1] This systematic review provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis, with some interventions showing moderate-to-large superior effects compared with others. (10.1016/j.jhsg.2021.02.003)
  • [L4] Finger forces are more hampered while gripping objects with smaller circumferences than large ones. (10.1177/17531934211061220)
  • [L4] The new Buttazzoni classification system is simple, covers all radial fracture types, and has acceptable reliability comparable to commonly used systems. (10.1007/s11552-009-9163-1)
  • [L4] The goal of surgical fixation is a stable reduced joint that will tolerate immediate postoperative range of motion. (10.2106/jbjs.rvw.m.00049)
  • [L4] The results provide new insight to the dynamics of hand movement as well as a basis for subsequent evaluations of movement patterns performed in ADLs and instrumental ADLs. (10.1007/s11552-013-9517-6)
  • [L4] Metallic hinged prostheses have been used to restore function in rheumatoid finger joints, with indications including gross joint destruction, dislocation, and persistent deformity. (10.2106/00004623-196143050-00011)
  • [L5] The paper recommends the adoption of the ObergeManskeeTonkin classification system to replace the Swanson classification, citing increased knowledge of molecular etiology and the need for a system that describes the limb axis and specific anomalies. (10.1016/j.jhsa.2014.12.001)
  • [L5] Ideally, digits need sensation and freedom of motion to enable patients to use them effectively, and effective surgery restores biomechanical motions so patients have optimum use. (10.1016/j.hcl.2013.08.003)
  • [L4] Management should be conservative, resisting surgical attempts to tighten the joint, and encouraging children to unlearn the habit. (10.1177/1753193416687915)
  • [L4] The proposed radiographic classification had prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures. (10.2106/00004623-198971090-00011)
  • [L4] Forearm positioning has great implications on daily functioning, as well as strength and skilled use of the hand. (10.1016/j.jht.2014.08.027)
  • [L4] It is unsuccessful when done in the face of poor indications, when the tendon is not freed completely, or when performed in association with complex orthopaedic procedures which do not permit early postoperative active motion. (10.2106/00004623-196749040-00009)
  • [L4] Nonoperative therapy is recommended as the initial treatment course. (10.1016/j.hcl.2008.03.002)
  • [L4] Fixation is possible up to 8 weeks after injury, though earlier treatment yields better range of motion outcomes. (10.1177/1753193413508514)
  • [L4] The authors propose an additional category (Type 3) to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual, which were not previously represented in existing classifications. (10.1016/j.jhsg.2023.10.005)
  • [L5] Additionally, surgical treatment targets treating joint imbalance to prevent fixed deformity. (10.1016/s0749-0712(03)00076-3)
  • [L5] Despite continued efforts to improve hand evaluation techniques, limitations in quantifying joint motion to exact precision persist even with in-person assessment. (10.1177/17531934231154158)
  • [L5] Using the proposed method, the thumb extension and abduction functions can be reconstructed without requiring a pulley. (10.1016/j.jhsg.2025.100781)
  • [L5] Mean forearm shortening of 3 or 4 cm resulted in near-complete loss of FDP simulated muscle force and tip-to-palm force in wrist-neutral and wrist-extension positions, respectively. (10.1016/j.jhsa.2024.09.005)
  • [L4] Currently, it is the most reliable tool for measuring thumb abduction. (10.1016/j.jht.2021.03.001)
  • [L5] Plain radiography provides the most basic and useful information, while MRI provides the most information about soft tissues. (10.1197/j.jht.2007.02.002)
  • [L5] Understanding foundational principles of anatomy and kinematics and initiating early mobilization are critical components in the treatment algorithm. (10.1177/17531934231185304)
  • [L4] There are different classification systems which were developed with various aims. (10.1016/j.jht.2023.05.008)
  • [L4] The authors propose a classification system to organize variations of the long extensor tendon to the thumb, aiming to help avoid confusion during surgeries involving repair or transfer of these tendons. (10.1007/s11552-010-9273-9)
  • [Commentary] The author argues that incongruous radiocarpal joints are well tolerated due to wrist biomechanics, particularly the role of the midcarpal joint in the dart-throwing motion, and questions the necessity of aggressive treatment for stepoffs larger than 1 mm. (10.1016/j.jhsa.2013.04.038)
  • [L4] Although there are limitations in the total degree of movement, the motion which persists is functional, pain relief has been substantial and the long term outcomes and follow-up suggest minimal deterioration. (10.1016/j.jhsa.2014.06.065)
  • [L5] The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis. (10.1007/s11552-013-9499-4)
  • [L4] No recurrence of radiocarpal translation was observed at long term follow-up. (10.1016/j.jhsg.2024.01.001)
  • [L4] Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after the injury. (10.1177/17531934231202012)
  • [L5] All imaging modalities (radiograph, CT, and MRI) demonstrated excellent inter-rater agreement with no significant difference in bias from the true variance when compared to each other. (10.1016/s0363-5023(11)60022-1)
  • [Paper] Soft tissue reconstructions alone are unlikely to correct deformity adequately or maintain correction long-term; joint procedures are preferred. (10.1016/j.hcl.2010.10.001)
  • [Case_report] Management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate. (10.1186/1749-799x-5-26)
  • [L3] No adverse events or revisions were reported. (10.1016/j.jhsa.2016.07.036)
  • [L4] No adverse events or revisions were reported. (10.1016/j.jhsa.2014.06.033)
  • [L5] The author notes that despite 70 years of research and numerous treatment options, the best management for trapeziometacarpal arthritis remains debated, with a constant proportion of patients remaining unhappy or symptomatic post-surgery. (10.1177/17531934221122987)
  • [L4] Conservative treatment is the initial approach, but surgical decompression is indicated if these measures fail. (10.2106/00004623-196951080-00016)
  • [L4] Nonoperative options are commonly used as first-line treatment for tenosynovitis of the hand and wrist, but questions remain regarding when to advance to operative intervention. (10.2106/jbjs.rvw.o.00061)
  • [L5] Management is dictated by classification, with initial conservative therapy followed by interventional options or surgery for persistent pain, swelling, or functional impairment. (10.5435/jaaos-22-06-352)
  • [L4] Radiological findings support good bone tolerance with signs of progressive integration, despite moderate erosion and bone remodeling in some cases. (10.1016/j.jhsg.2025.100804)
  • [L5] The overall health of the child and the severity of deformities guide long-term treatment plans aimed at realigning the forearm, wrist, and hand while providing a functional thumb. (10.5435/00124635-200701000-00005)
  • [L2] MRI alters the treatment of hand, wrist, and elbow conditions in less than 1 in 5 patients. (10.1177/1558944719861725)
  • [Letter] Thumb CMC joint arthritis is an expected part of aging, and many patients may become asymptomatic or minimally symptomatic; therefore, nonoperative care including therapy should be offered as first-line treatment as patients may find relief and never proceed with surgery. (10.1016/j.jht.2023.03.002)
  • [L4] Advanced imaging (bone scintigraphy and single-photon emission CT and standard CT) are helpful to confirm the diagnosis. (10.1016/j.jhsa.2021.02.017)
  • [L5] Vascularized bone graft is recommended when osteonecrosis of the proximal pole is evident on MRI. (10.5435/00124635-199407000-00001)
  • [Case_report] Conservative management resulted in a satisfactory short-term outcome for this elderly, low-demand patient with minimal symptoms. (10.1016/j.jhsg.2021.10.002)
  • [L4] This technique is advocated for complex recalcitrant non-unions where conventional grafts may fail due to poor vascularity. (10.2106/00004623-199072010-00015)
  • [Case_report] The early radiographic results of this reconstruction are promising. (10.1007/s11552-011-9361-5)
  • [L5] Standard radiographs provide between 53% and 90% sensitivity, while CT offers 94% specificity and 97% accuracy. (10.1016/j.jhsa.2013.06.004)
  • [Paper] MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers. (10.1016/s0363-5023(10)60085-8)
  • [L4] The patient remained pain- and symptom-free at 14 months with full range of motion and no recurrence on MRI. (10.1016/j.jhsg.2020.04.002)
  • [L5] The mandatory imaging work-up consists of radiographs and ultrasound, while MRI should be requested any time there are atypical findings such as bone extension of a soft tissue lesion, osteolysis, or size greater than 3 cm. (10.1016/j.otsr.2021.103153)
  • [L3] Patients requiring arthrodesis or amputation tended to be men in their sixties with comorbidities, an idiopathic cause, and delayed presentation. (10.1016/s0363-5023(10)60129-3)
  • [L4] The study describes the characteristics of the preserved anlage before and after surgical correction, noting that mild IP joint deformity may persist without functional impairment. (10.1177/1753193420948383)
  • [L4] The articular surface of the scaphoid remodels over time in skeletally mature subjects, with normal architecture completely restored by 3 years. (10.1007/s11552-010-9264-x)
  • [L4] Union was achieved in a relatively short period of time with a nonvascularised bone graft. (10.1177/1753193408090120)
  • [L4] The patient was free of pain with essentially normal range of motion at thirty-four months follow-up. (10.2106/00004623-198163060-00021)
  • [L4] Surgical removal of the cartilaginous ridge restored normal joint motion and the patient remained free of symptoms. (10.2106/00004623-196143020-00012)
  • [L4] While degenerative changes may occur, they did not necessarily result in disabling symptoms at the time of follow-up. (10.2106/00004623-197961060-00018)
  • [L5] Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis is likely to lead to progression of joint degeneration, and recognition of this incongruity can lead to measures that may prevent or delay this progression. (10.1177/17531934221137780)

See Also

References

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[32] The importance of identifying red flags in patients with elbow pain: A systematic review. Journal of Hand Therapy. 2026. DOI: 10.1016/j.jht.2026.02.009

[33] Achieving balance in upper limb spasticity management. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261434453

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[39] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[40] Biomechanical Comparison of Plate Versus Intramedullary Screw Fixation for Extra-Articular Metacarpal Base Fractures. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100897

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[72] Virtual goniometric assessment of finger motion: commentary and personal opinion. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231154158

[73] Extensor Pollicis Brevis Tendon Transfer for Thumb Reconstruction in Radial Nerve Palsy: A Comparative Cadaveric Study. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100781

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[92] Functional Recovery From the Utilization of Processed Nerve Allografts for Large Gap Nerve Discontinuities: Outcomes From a National Registry Study. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.033

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[97] Functional Outcomes of Spherical Pyrocarbon HAPY Metacarpophalangeal Interposition Arthroplasty for Long Fingers: A Retrospective Study of 16 Cases. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100804

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[99] MRI Utility in Hand Surgery. HAND. 2019. DOI: 10.1177/1558944719861725

[100] Letter to editor: The biomechanics of osteoarthritis in the hand: Implications and prospects for hand therapy. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.03.002

[101] Thumb Metacarpal-Trapezoid Impingement as an Etiology of Pain After Trapeziectomy and Basal Joint Soft Tissue Arthroplasty: A Case Series. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.02.017

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[121] Trapeziometarpal joint arthritis in the young patient. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934221137780

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