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Bones and Joints

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

219 citationsUpdated Sep 2026

Overview¶

Surgical management of hand and wrist osteoarthritis, including fusion and arthroplasty, is tailored to the specific joint involved, patient demands, and complication risks [1]. Intraoperative assessment of articular surfaces is recommended over preoperative radiographs for selecting between proximal row carpectomy and scaphoid excision with intercarpal arthrodesis [3]. The choice between arthroplasty and arthrodesis requires careful consideration of individual patient needs [8]. For distal radioulnar joint pathology in rheumatoid arthritis, outcomes are optimal when surgery precedes severe joint destruction, fixed contractures, subluxation, or dislocation [10]. Fractures with less than 30% joint involvement managed nonsurgically have demonstrated positive outcomes [9].

Arthrodesis remains the primary procedure for scaphotrapezio-trapezoid arthritis, though outcomes are mixed due to risks of nonunion and adjacent joint arthritis [15]. Pain relief from hand arthroplasty is generally good, but high rates of deformity recurrence and complications depend on implant type and joint involved [34]. Total joint replacement for thumb carpometacarpal osteoarthritis offers advantages such as restored length, alignment, and faster recovery, though it is technically demanding with a potentially higher complication rate [176]. MCP arthroplasty is the procedure of choice at the CMC joint, while arthrodesis is usual at the IP level, aiming to maintain mobility in as many joints as possible [60].

Functional range of motion directs surgical indications, rehabilitation, and outcome assessment [37]. The goal of surgical fixation for Monteggia and transolecranon fracture-dislocations is a stable reduced joint tolerating immediate postoperative range of motion [47]. Immediate repair is generally preferred for thumb metacarpophalangeal ligament injury, though delayed repair up to 6 weeks may be possible; deferral risks chronic instability and arthrosis [64]. Tenolysis is unsuccessful when indications are poor, the tendon is not freed completely, or it is performed with complex procedures preventing early active motion [147]. Bone lengthening in the pediatric upper extremity carries a high complication rate, with success defined by radiographic lengthening, joint motion, and patient satisfaction rather than validated outcome measures [12].

Anatomy & Pathophysiology¶

Bony Anatomy and Skeletal Development¶

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [24]. The hand itself consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [20]. The skeleton is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [24]. The base of each metacarpal articulates with the distal carpal row, while the carpus connects to the forearm via its proximal row [24]. The radioulno-carpal articulation possesses two axes of movement, supplemented by a third axis of pronation and supination from the forearm, allowing the wrist to position the hand in any spatial configuration [24].

The radial ray, or first ray, is the shortest, comprising only a metacarpal and two phalanges [24]. It continues the external carpal column formed by the scaphoid and trapezium [24]. The trapezium is angled anteriorly out of the carpal plane, creating an approximately 45-degree angle between the first and second metacarpals in the sagittal plane [24]. Regarding length, the thumb metacarpal is the shortest, the index finger is the longest, and the remaining digits decrease in length from third to fifth [24]. The proximal and middle phalanges of the middle and ring fingers are longer than those of the index finger [24]. The hand skeleton exhibits longitudinal and transverse concavities, forming a cup shape with palmar concavity when the thumb opposes the index finger [24]. The transverse axis of the palm is oblique, positioned more distally at the index metacarpophalangeal joint and more proximally at the fifth metacarpophalangeal joint, forming an acute angle of approximately 75 degrees with the longitudinal axis [24].

Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, and at the distal ends of the other metacarpals [24]. Embryonic limb development begins with arm buds at approximately 4 weeks post-ovulation, followed shortly by leg buds [80]. Finger and toe rays differentiate by around 5 weeks [80]. From about 6 weeks, primitive cartilaginous bone models become vascularized, and primary ossification centers appear in the chondroid anlage [80]. Cavitation occurs at 7–8 weeks where joints will form, and between 8 and 12 weeks, primitive joints and synovium become defined [80]. Secondary ossification centers appear in the cartilaginous ends of tubular bones soon after birth [80]. Longitudinal growth continues until late adolescence via endochondral bone formation, ceasing when the growth plate ossifies and fuses the epiphysis to the metaphysis [80]. Bone circumference increases through periosteal bone formation, a process that does not involve intermediary cartilage and may continue throughout life depending on anatomical site [80]. The vertebrate skeleton consists of 206 bones of varying shapes and sizes [73].

Joint Mechanics and Kinematics¶

The metacarpophalangeal joint possesses five kinematic degrees of freedom from a mechanical perspective [101]. During thumb opposition, internal rotation of the first metacarpal occurs, with the palmar base rotating primarily relative to the dorsal base [190]. The position of the thumb interphalangeal joint influences trapeziometacarpal joint movements and thenar muscle activity during opposition [209]. Wrist biomechanics are significantly altered following trapeziectomy, with LRTI reconstruction most closely resembling intact biomechanics in cadaveric models [108]. Distal radius fractures interfere with wrist biomechanical integrity, limiting range of motion and affecting hand muscle strength [126].

The scaphoid acts as a mechanical link stabilizing the intercarpal joint during wrist motion [290]. Without scaphoid stability, the proximal carpal row functions as an unsupported intercalated link in a three-link system, resulting in zigzag collapse under axial loading [290]. Dorsiflexion instability, characterized by lunate dorsiflexion within the linkage, commonly occurs after scaphoid fracture and scapholunate dissociation [290]. In scapholunate dissociation, the scaphoid assumes a vertical position, with the angle between the longitudinal axes of the scaphoid and lunate approaching a right angle [290]. Rupture of the distal attachments of the palmar radiocarpal ligament and the scapholunate ligament induces dissociation [290]. Ligamentous injury accompanying scaphoid fracture is likely necessary for dorsiflexion instability to develop [290]. Palmar flexion instability, characterized by lunate palmar flexion, is associated with ulnar displacement of the carpus [290]. The direction of intercarpal collapse relates to the location of capitate head pressure against the lunate’s concave surface and whether this pressure is dorsal or palmar to the plane of the radiolunate fulcrum on the lunate’s proximal convex surface [290].

Incongruous radiocarpal joints are well tolerated due to wrist biomechanics, particularly the midcarpal joint’s role in dart-throwing motion [169]. Bone-ligament-bone reconstruction displays physiologic carpal kinematics in adjacent joints compared with arthrodesis [178]. The effect of lunate morphology on three-dimensional carpal kinematics during wrist flexion and extension has been described [122]. Forearm positioning significantly impacts daily functioning, strength, and skilled hand use [146]. Mean forearm shortening of 3 or 4 cm results in near-complete loss of FDP simulated muscle force and tip-to-palm force in wrist-neutral and wrist-extension positions, respectively [157]. Detailed descriptions of forearm kinematics provide new insight into hand movement dynamics and serve as a basis for evaluating movement patterns in activities of daily living [77, 136]. Despite improvements in hand evaluation techniques, limitations in quantifying joint motion to exact precision persist even with in-person assessment [153]. Quantification of thumb kinematics aids in understanding motor dysfunction in carpal tunnel syndrome, assessing severity, and deciding on treatment [191]. Three-dimensional motion analysis is expected to be used for assessing carpal tunnel syndrome severity and thumb motor function post-treatment [191]. These findings contribute to understanding wrist joint injury mechanisms, developing preventative measures, and designing engineering or rehabilitation devices [182]. With increased focus on dynamic imaging for wrist motion, it may be possible to derive a standardized, clinically applicable, and reproducible protocol for mapping carpal motion [202]. Understanding morphology may provide insight into the biomechanics and disease progression within the distal interphalangeal joints [174]. Littler correctly intuited important mathematical relationships of the hand; the functional lengths of the little finger phalanges follow a Fibonacci series, while the lengths for the index, long, and ring fingers follow a related pattern called the Littler series [187].

Muscular Anatomy and Function¶

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [22]. Extrinsic muscles originate outside the hand and insert on the hand or carpus, functioning as either flexors or extensors [22]. Intrinsic muscles have both origin and insertion within the hand and contribute to both digital flexion and extension [22].

Extrinsic Extensors: The extrinsic extensors run through six fibroosseous retinacular compartments at the wrist [22]. First Compartment: Contains the abductor pollicis longus and extensor pollicis brevis [22]. The abductor pollicis longus has multiple slips inserting at the base of the thumb metacarpal, radially abducting the thumb [22]. The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the thumb proximal phalanx, actively extending the thumb metacarpophalangeal joint [22]. Second Compartment: Contains the extensor carpi radialis longus and extensor carpi radialis brevis [22]. The extensor carpi radialis longus inserts on the index metacarpal, dorsiflexing and radially deviating the wrist [22]. The extensor carpi radialis brevis inserts into the base of the middle metacarpal, providing balanced wrist dorsiflexion [22]. Third Compartment: Contains the extensor pollicis longus [22]. This tendon runs longitudinally down the forearm, turns abruptly radialward about Lister tubercle, and provides forceful extension of the thumb interphalangeal joint [22]. Its oblique course provides a substantial adduction component to its pull [22]. Fourth Compartment: Contains the extensor indicis proprius, lying deep to the four tendons of the extensor digitorum communis [22]. The extensor indicis proprius inserts on the index finger ulnar to the extensor digitorum communis [22]. It may be recognized at the wrist level as possessing the most distal muscle belly of any digital extensor tendon [22]. Fifth Compartment: Contains the extensor digiti quinti [22]. The extensor digiti quinti tendon inserts on the little finger ulnar to the extensor digitorum communis insertion [22]. The extensor indicis proprius, extensor digitorum communis, and extensor digiti quinti each contribute to digital extension at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints [22]. The extensor digitorum communis inserts on the index, middle, ring, and, in some cases, little fingers [22]. The principal bony insertion of extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [22]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [22]. Sixth Compartment: Contains the extensor carpi ulnaris, which inserts at the base of the little finger metacarpal, providing wrist extension and ulnar deviation [22].

Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [22]. Distal interphalangeal joint extension is achieved through conjoined lateral bands composed of tendinous slips from extrinsic and intrinsic tendons [22]. Digital extensor tendons are stabilized over the midline of the metacarpophalangeal joint by attachment to sagittal band fibers [22]. These fibers insert onto the volar proximal phalanx and the lateral borders of the volar plate, forming a sling that transmits proximal extrinsic extensor tension to the proximal phalanx, permitting metacarpophalangeal joint extension without a direct tendinous insertion onto the proximal phalanx [22]. By holding the extrinsic extensor tendon balanced over the metacarpal head prominence, sagittal bands keep the tendon as far as possible from the center of rotation of the metacarpophalangeal joint, maximizing mechanical efficiency [22]. Rupture or attenuation of sagittal band fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [22].

Extrinsic Flexors: The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [22, 88]. The flexor digitorum profundus originates from the proximal ulna and interosseous membrane [88]. In the forearm, it divides into a radial component supplying the index finger and an ulnar component supplying the middle, ring, and little fingers [88]. The flexor digitorum profundus and flexor pollicis longus form the deep compartment of the volar forearm and occupy the floor of the carpal tunnel [88]. The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa, while the sheath to the little finger is continuous with the ulnar digital bursa [88]. In some patients, these bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger if infection occurs in either flexor tendon sheath [88]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints [22, 88]. The profundus tendon passes through the bifurcation of the flexor digitorum superficialis before inserting into the proximal palmar base of the distal phalanx [88]. Innervation of the flexor digitorum profundus for the index and middle fingers is via the anterior interosseous branch of the median nerve, while the ring and little finger components are innervated by the ulnar nerve [88].

The flexor digitorum superficialis has two heads: a radial head originating from the proximal radius shaft, and a humeral ulnar head originating from the medial humeral epicondyle and coronoid process of the ulna [88]. Each digit has a corresponding independent superficialis muscle [88]. As the tendons pass through the carpal tunnel, those of the middle and ring fingers are more superficial and central than those of the index and little fingers [88]. In the proximal finger, the flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [88]. The tendon slips reunite distally at the Camper chiasm, with approximately half of the fibers staying on the ipsilateral side and half crossing to the contralateral side [88]. The tendon then inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [88]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve [88]. Its primary function is digital flexion at the proximal interphalangeal joint [88]. The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [88].

Classification¶

General Principles and Reliability¶

No single radiological classification of trapeziometacarpal osteoarthritis accurately describes all stages to permit reliable and consistent communication between clinicians [6]. The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria [196]. Similarly, several classification schemes for scaphoid nonunions have been proposed but are not all-encompassing with regard to nonunion characteristics and treatment options [252]. An ideal classification system for congenital hand differences should incorporate etiology, diagnosis, treatment, and prognosis, be detailed enough to differentiate among various differences but not too cumbersome to be useful, and be widely accepted to facilitate standardized communication [181].

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 [39]. The new Buttazzoni classification system for distal radial fractures is simple, covers all radial fracture types, and has acceptable reliability comparable to commonly used systems [131]. A new, reliable radiographic classification system for synpolydactyly allows improved communication between clinicians and serves as a foundation for future investigations [116]. Different classification systems have been developed with various aims for upper limb orthoses [166].

The proposed radiographic classification for coronoid process fractures had prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures [145]. A classification system (Type I, II, III) for trans-trapezium carpometacarpal dislocation of the thumb aids management [204]. A simplified classification system for radial polydactyly brings surgical management closer to a unifying approach, aiming to address at least 95% of all cases [205]. This system supplements Wassel's classification by providing clear guidance on surgical methods and required surgeon expertise levels [193]. A modified classification provides a practical and utilitarian scheme for nomenclature of radial polydactyly that may assist comparison of treatment outcomes and individual cases [180].

A novel classification system for hamatometacarpal fracture-dislocation can be used to establish guidelines for appropriate treatment [41]. A classification system organizes variations of the long extensor tendon to the thumb, aiming to help avoid confusion during surgeries involving repair or transfer of these tendons [167]. An additional category (Type 3) to the Türker classification system encompasses rare findings of two radial-sided accessory extensor tendons in the same individual [151]. Subgroups in Bado's classification of Monteggia fracture-dislocations (Type IV-A through IV-D) are based on the direction of angulation and dislocation [203]. Classifications for distal radius fractures help to identify unstable fractures and offer insight into the indications for external skeletal fixation [170].

The ObergeManskeeTonkin classification system is recommended 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 [138]. The 2020 OMT classification update streamlines terminology and reorganizes categories, such as moving arthrogryposis to a dedicated 'dysplasias – congenital contracture' group, to improve clinical utility and reflect current understanding of limb development and genetics [195]. The Unified Classification System guides management of periprosthetic fractures around Motec implants [186]. One cannot rely entirely on the existing anatomical classifications of the median nerve in the carpal tunnel [192].

Specific Joint and Bone Classifications¶

Burton: The Burton classification system for trapeziometacarpal arthritis utilizes clinical signs, patient symptoms, and radiographs. Stage I is characterized by pain, a positive grind test, and ligamentous laxity with dorsoradial subluxation [14]. Stage II demonstrates increased instability, chronic subluxation, and degenerative changes evidenced by radiograph [14]. Stage III involves further progression of degeneration to involve the scaphotrapezial joint [14]. Stage IV is defined as either Stage II or III with metacarpophalangeal joint changes [14].

Eaton: The Eaton classification for CMC arthritis relies on radiographic changes only [14]. Eaton and Glickel described a radiographic staging system for basal joint arthritis where Stage I demonstrates mild subluxation and no joint space narrowing [229]. Stage II shows evidence of arthritis limited to the trapeziometacarpal joint with osteophytes <2 mm in diameter [229]. Stage III is described as sclerosis of the subchondral bone and/or osteophytes >2 mm [229]. Stage IV involves both the trapeziometacarpal joint and the scaphotrapezial joint [229].

Lichtman: The most widely used classification for Kienböck’s disease is the four-stage classification described by Lichtman et al. (1977), which is based on plain radiographs and describes osseous morphological characteristics [66].

Bain and Begg: Bain and Begg developed an arthroscopic four-stage classification for Kienböck’s disease based on cartilage status, considered a cartilage classification [66].

Schmitt: Schmitt et al. developed a three-stage classification for Kienböck’s disease based on signal intensity in different zones of the lunate on gadolinium-enhanced MRI, considered a vascular, perfusion, or viability classification [66].

Herbert and Lanzetta: The Herbert and Lanzetta classification for Preiser's disease is based on the progression of the disease as seen with plain radiographs and consists of four stages [69]. Stage 1 involves normal radiographs but a positive bone scan [69]. Stage 4 involves total collapse of the scaphoid and periscaphoid arthritis [69].

Palmer: The Palmer classification classifies tears of the triangular fibrocartilage complex, with Class 1 tears being traumatic and Class 2 tears being degenerative [278]. Class 1A tears are central perforations with a low risk of distal radioulnar joint instability [278]. Class 1B tears are ulnar avulsions (with or without distal ulnar fracture) with a high risk of distal radioulnar joint instability [278]. Class 1C tears are distal avulsions with a high risk of distal radioulnar joint instability [278]. Class 1D tears are radial avulsions (with or without sigmoid notch fracture) with a high risk of distal radioulnar joint instability [278].

Metacarpal Synostosis: A classification system for metacarpal synostosis of the ring and little fingers is based on the fourth-fifth intermetacarpal angle (IMA) and the presence of severe shortening of the fifth ray [245]. Type A is defined as a narrow IMA type where the IMA is less than normal [245]. Type B is defined as a wide IMA type where the degree of IMA is larger than normal [245]. Type C is defined as a reverse IMA type (convergent type) where the IMA is a negative value [245].

Congenital Thumb Hypoplasia: A proposed classification for congenital thumb hypoplasia maintains the integrity of Blauth’s skeletal classification and the teratological sequence of increasing severity of hypoplasia proposed by Müller, Blauth and others [280]. Grade 1 is characterized by a small thumb, some hypoplasia of the thenar musculature, and stable and mobile joints with no surgery indicated [280]. Grade 2 is characterized by more severe hypoplasia where the CMC joint is present, with MP joint instability and first web underdevelopment [280]. Grade 2A is defined as mild hypoplasia with uniaxial MP joint instability and adduction of the first metacarpal with first web deficiency [280]. Grade 2B is defined as moderate hypoplasia with more severe intrinsic hypoplasia and first web insufficiency, and multiplanar MP joint instability [280].

Tumour Staging¶

Enneking: The Enneking staging system classifies tumours according to whether they are high or low grade, whether there are metastases present or not, and whether the tumour has grown out of its original compartment or remains confined to a compartment [154]. Stage 1A is defined as a low-grade, intracompartmental tumour [154]. Stage 1B is defined as a low-grade, extracompartmental tumour [154]. Stage 2A is defined as a high-grade, intracompartmental tumour [154]. Stage 2B is defined as a high-grade, extracompartmental tumour [154]. Stage 3 is defined as any of the above stages with metastases [154].

TNM: The TNM staging system for primary sarcomas of bone takes into consideration the histological subtype, size, continuity, grade, and local and distant spread of the tumour [154]. In the TNM staging system for bone sarcomas, size is dichotomized to small (<8 cm) or large (>8 cm) [154]. In the TNM staging system for soft-tissue sarcomas, size is dichotomized to small (<5 cm) or large (>5 cm) [154]. Stage 1A is defined as low-grade, small, no metastases [154]. Stage 1B is defined as low-grade, large, no metastases [154]. Stage 2A is defined as intermediate- or high-grade, small, no metastases [154]. Stage 2B is defined as intermediate-grade, large, no metastases [154]. Stage 3 is defined as high-grade, large, no metastases [154]. Stage 4 is defined as any with metastases [154].

Other Considerations: Cases of pathologic fractures in benign neoplasms of the fingers were staged according to both the Modified Lodwick-Madewell and Enneking classification systems [272].

Clinical Presentation¶

History and General Evaluation¶

Patients often struggle to accurately describe symptoms and may incorrectly attribute pathology to a perceived deficit [5]. A careful physical examination is essential to direct care and future testing if indicated [5]. Because of the high density of structures in a small space, a systematic method for approaching the physical examination of the hand and wrist is essential [5]. In most cases, evaluation of upper limb joint function can be performed using only clinical means without instruments [107]. For musculoskeletal tumors, an adequate history and physical examination are the first steps in evaluation [148]. Age is often the most important historical information, as most benign and malignant musculoskeletal neoplasms occur within specific age ranges [148].

Tumor-Specific Symptoms¶

Patients with bone tumors most frequently present with pain [148]. Malignancy of bone typically presents with progressive pain at rest and at night [148]. Benign bone tumors may cause activity-related pain if the lesion is large enough to weaken the bone [148]. Osteoid osteoma may cause night pain initially [148]. Conversely, patients with soft-tissue tumors rarely complain of pain but more often report a mass [148].

Diagnostic Challenges and Red Flags¶

A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis [2]. Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain [23]. When elbow pain is accompanied by musculoskeletal or systemic red flags, clinicians should perform a structured assessment and refer promptly [78]. In pediatric cases of bizarre parosteal osteochondromatous proliferation, diagnosis can be challenging due to presenting symptoms and radiographic findings [27]. 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 [95].

The development of a trigger wrist is atypical, with multiple causes for its development [104]. Differentiating tenosynovitis with psammomatous calcification from intra-articular lesions is important, particularly in atypical presentations [103]. Metacarpal head osteochondroma should be included in the differential diagnosis of a 'trigger finger' [115]. Advanced imaging is critical for identifying bony prominences causing locking when common etiologies are absent [115]. 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 wrist pain [29]. Associated medical and musculoskeletal conditions are common in patients with ulnar longitudinal deficiency, of which cardiac and lower extremity abnormalities are most frequently observed [109].

Specific Joint Pathologies¶

Disorders of the distal radioulnar joint are a common source of ulnar-sided wrist pain [100]. In scleroderma, joint pain is exceedingly common, with some studies reporting arthralgias in up to 66% to 97% patients [132]. Arthralgias can be the presenting symptom of scleroderma, with up to 20% complaining of joint pain before scleroderma diagnosis [132]. Synovitis and arthritis on clinical examination can present in up to 46% of patients with scleroderma [132]. Subclinical synovitis can be detected in a much higher proportion on imaging studies than on clinical examination in patients with scleroderma [132]. The most common radiographic presentation of joint pathology in scleroderma is joint space narrowing with or without bony changes [132].

Boxer's knuckle refers to an injury or tear of the metacarpophalangeal joint capsule [26]. Injuries to the metacarpophalangeal joint capsule are most commonly attritional because of repetitive trauma and progressive capsular attenuation [26]. Forceful hyperflexion of the metacarpophalangeal joint leads to tensioning of the capsule and extensor hood over the narrow dorsal ridge of the metacarpal head, making it vulnerable to injury from a direct blow [26]. Athletes competing in boxing, martial arts, or other combat sports are at particular risk for metacarpophalangeal joint capsule injuries [26]. Chronic metacarpophalangeal joint capsule injuries may exhibit thickening of the extensor mechanism on examination due to scar tissue formation [26]. A subtle but detectable defect in the dorsal joint capsule is often palpable radial, ulnar, or deep to the extensor tendon and is the hallmark examination finding for metacarpophalangeal joint capsule injuries [26].

In lumbrical-interosseous syndrome, adhesions between the lumbrical and interosseous muscles form distal to the deep transverse metacarpal ligament [26]. Proximal pull of the adhesions during intrinsic muscle contraction leads to impingement against the deep transverse metacarpal ligament, presenting clinically as the inability to achieve an intrinsic plus position [26]. Definitive diagnosis and appropriate management are required for any locking of the metacarpophalangeal joint to prevent fixed flexion contracture and permanent disability [106].

The diagnosis of thumb carpometacarpal joint arthritis is heavily dependent on physical examination [124]. The grind test is performed by circumducting the thumb metacarpal while compressing the joint axially and is considered positive if it elicits pain [124]. A recent study concluded adduction and extension manoeuvres are more accurate than the grind test for diagnosing carpometacarpal arthritis [124]. Choa et al. demonstrated a ‘traction-shift’ test as a superior method of diagnosing carpometacarpal arthritis compared with the grind test [124]. There is a lack of accuracy and a relatively high incidence of false negative results for the grind test in carpometacarpal arthritis [124]. The reduction manoeuvre was more sensitive and specific than the grind or shift tests for diagnosing carpometacarpal arthritis [124]. Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis is likely to lead to progression of joint degeneration [42]. Recognition of joint incongruity in early-stage trapeziometacarpal arthritis can lead to measures that may prevent or delay this progression [42].

Imaging and Diagnostic Modalities¶

Diagnostic tests such as imaging and serum laboratory studies are useful in determining hand and wrist pathology but can be expensive, time consuming, and often nonspecific [5]. While in-person physical examination remains necessary, objective radiographic data may aid in preliminary diagnosis and treatment recommendations [25]. Diagnosis of congenital absence of flexor pollicis longus tendon can be confirmed using physical examination, direct radiography, and magnetic resonance imaging [30]. 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 [32]. Imaging techniques allow better understanding of conditions that affect the shoulder [44]. Obtaining x-rays or radiology reports allows a rehabilitation specialist the opportunity to obtain valuable information about the patient, which can then be used to improve the clinical treatment plan and lead to a better outcome [48].

Radiographs can be used to observe the bony cortex for irregularities, the joint spaces to detect normal spacing or narrowing of joint spaces, sclerotic changes near joint surfaces suggestive of abnormal force transmission, and bone density changes in the specific area of patient complaint [48]. Typically, more than one view of the injured body part is taken and occasionally the opposite extremity is studied as well for comparison purposes [48]. Plain radiography is the principal diagnostic modality for fractures of the metacarpal bases [135]. Lateral radiographs should be closely investigated for dorsal displacement and subluxation or dislocation of the metacarpal bases from the carpal row [135]. Standard radiographs can prove inconclusive or negative for metacarpal base fractures because the overlying trapezium, trapezoid, or hamate may obscure the fracture pattern [135]. Additional radiographic views such as semisupination anteroposterior, slightly off-lateral, posteroanterior adduction, or 30° anterior oblique may allow proper visualization of the articular surface and assist in diagnosis of metacarpal base fractures [135]. Fragment rotation may be difficult to appreciate even if a fracture line is identified on plain radiographs [135]. Advanced imaging modalities such as bone scintigraphy or computed tomography may help to identify and further characterize the fracture pattern of metacarpal base fractures [135]. Computed tomography may aid in the recognition of a previously unidentified rotational deformity in metacarpal base fractures, which could affect treatment decisions [135].

Careful clinical and radiographic evaluation are required for carpometacarpal joint dislocations and fracture dislocations of the index through small digits [134]. ChatGPT 4.0 technology is not currently able to consistently and reliably provide accurate diagnoses when prompted with radiologic studies of common orthopedic upper extremity pathologies [110]. The radiological classification does not describe all stages of carpometacarpal joint osteoarthritis accurately enough to permit reliable and consistent communication between clinicians [6]. Anteroposterior radiographs of the right hand can be used to observe pathological alterations of metaphysis, distal end of phalanges, epiphysis, and carpals in Kashin-Beck disease [137]. Clinical symptoms checked for Kashin-Beck disease include joint pain, morning stiffness, and joint friction sound [137]. X-ray pathological changes for Kashin-Beck disease include metaphysis alterations, distal end of phalanges changes, epiphysis changes, and carpal changes [137].

Investigations¶

Clinical Examination¶

A careful physical examination is essential to direct care and future testing, as diagnostic tests such as imaging and serum laboratory studies can be expensive, time-consuming, and often nonspecific [5]. Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit, whether real or imagined [5]. A systematic method is essential for approaching the physical examination of the hand and wrist due to the high density of structures in a small space [5]. The hand is both an organ designed to obtain information and an organ of execution [20]. It functions efficiently only if the proximal joints of the limb are stable and yet mobile [20]. The combined movements of the wrist and forearm place the hand in a position for grasping [20]. For gripping, the wrist is usually in flexion when close to the trunk and in extension when placed at a distance [20]. Forearm rotation (pronation–supination) plays an important role, particularly for bringing food to the mouth [20].

The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand, and about the same number of tendons activated by the forearm muscles [20]. The thumb metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [24]. The transverse axis of the palm forms an acute angle of approximately 75 degrees with the longitudinal axis [24]. The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [24]. The third compartment contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle [22]. The sixth compartment contains the extensor carpi ulnaris tendon [22]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [22].

Plain radiography¶

Radiographs allow observation of the bony cortex for irregularities, joint spaces for normal spacing or narrowing, sclerotic changes near joint surfaces suggestive of abnormal force transmission, and bone density changes in the specific area of patient complaint [48]. Standard radiographs provide between 53% and 90% sensitivity for hook of hamate fractures [238]. Radiographic development of trapeziometacarpal arthrosis is an expected part of human aging, although clinically significant, functionally limiting trapeziometacarpal arthrosis is less common [277]. The development of clinically significant trapeziometacarpal arthrosis may be unrelated to hand use [277]. While in-person physical examination remains necessary, objective radiographic data may aid in preliminary diagnosis and treatment recommendations for Blauth Type III thumb hypoplasia [25]. Where a pseudoepiphysis is seen on the radiographs of a healthy asymptomatic child, the patient and their family should simply be reassured [249].

Radiographic reduction was maintained in all patients in a retrospective case series of suture-button stabilisation for thumb carpometacarpal joint instability and dislocation [270]. Delayed diagnosis makes closed reduction difficult and was associated with less favorable radiographic outcome in carpometacarpal fracture-dislocations [67]. 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 [11]. Only in the limited group of cases with a clinical, radiographical, or a high index of suspicion of an occult or difficult to visualise fracture, extensive radiographic procedures should be performed [274].

Computed Tomography (CT)¶

Advanced imaging including standard CT is helpful to confirm the diagnosis of thumb metacarpal-trapezoid impingement [225]. CT offers 94% specificity and 97% accuracy for hook of hamate fractures [238]. 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 for ulnar variance [200]. The use of photon-counting detector computed tomography (PCD-CT) is likely to revolutionize many fields of medical imaging, with improvements in image resolution and versatility especially benefiting musculoskeletal imaging [258].

Magnetic Resonance Imaging (MRI)¶

MRI alters the treatment of hand, wrist, and elbow conditions in less than 1 in 5 patients [222]. MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers [241]. Vascularized bone graft is recommended when osteonecrosis of the proximal pole is evident on MRI for scaphoid nonunion [226]. MRI and ultrasound are the preeminent diagnostic tools for injuries to the finger flexor pulley system in rock climbers [281]. MRI determination of posterior interosseous nerve (PIN) position is reliable and consistent with prior cadaveric study [257].

MRI identified the cartilaginous configuration precisely in Wassel Type IV duplicated thumbs, which assisted in choosing the correct site to perform osteotomies and eliminated the need for secondary operations [260]. Magnetic resonance imaging demonstrated preservation of capitate morphology and reduced signal abnormalities in a case of capitate osteonecrosis in a patient with thalassemia [236]. MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing in Dupuytren’s disease [114]. MR assessment of Dupuytren’s is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [114]. MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas in Dupuytren’s disease, which is an index of biologic activity [114]. Advanced imaging including single-photon emission CT and standard CT are helpful to confirm the diagnosis of thumb metacarpal-trapezoid impingement [225].

Ultrasonography¶

Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions [268]. The mandatory imaging work-up for hand tumors consists of radiographs and ultrasound [243]. 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 in hand tumors [243]. An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [114]. False-negatives are possible with 8-MHz Doppler tone assessment for identifying neurovascular bundles in Dupuytren’s disease [114]. Ultrasound imaging is used to visualize tendon, pedicle, cord, and Dupuytren cord during needle aponeurotomy [114].

Other Considerations¶

This review provides an overview of current diagnostic imaging technologies and their clinical application for common conditions of the hand, wrist, and forearm, while also considering evolving and future imaging technologies [246]. The authors recommend intraoperative assessment of articular surfaces rather than preoperative radiographs for selecting the surgical procedure in proximal row carpectomy versus scaphoid excision and intercarpal arthrodesis [3]. Prompt diagnosis and surgical excision may prevent irreversible articular damage in osteoid osteoma of the scaphoid presenting with radiocarpal arthritis [7]. Radiological findings support good bone tolerance with signs of progressive integration, despite moderate erosion and bone remodeling in some cases of spherical pyrocarbon HAPY metacarpophalangeal interposition arthroplasty [220]. The early radiographic results of triquetral autograft for restoration of the lunate fossa of the distal radius are promising [233]. Prospective follow-up of over 200 patients has shown that both radiographic measures and patient-reported outcomes turned out great for vascularized bone flaps for carpal reconstruction [13]. The patient remained pain- and symptom-free at 14 months with full range of motion and no recurrence on MRI following treatment for a juxta-articular myxoma of the thumb [45].

Treatment¶

Non-Operative¶

Initial management for articular cartilage injuries typically involves a trial of nonsurgical measures, including rest, activity modification, anti-inflammatory medications, physical therapy, bracing, or injections [87]. Patients who fail to respond to these conservative measures may benefit from surgical intervention [87]. For tenosynovitis of the hand and wrist, nonoperative options serve as first-line treatment [217]. Similarly, conservative treatment is the initial approach for Extensor Indicis Proprius Syndrome, with surgical decompression reserved for cases where these measures fail [216]. In thumb CMC joint arthritis, nonoperative care including therapy is offered as first-line treatment because many patients may become asymptomatic or minimally symptomatic [223]. Conservative options for CMC arthritis include exercises, multimodal therapy, and rigid splinting, with hand-exercise programs specifically improving short-term grip strength [240].

Conservative management is also indicated for specific fracture and dislocation patterns. It is the standard of care for isolated spiral fractures of the right fourth metacarpal, yielding favorable short-term outcomes and rapid return to function [163]. For pediatric volar plate avulsion fractures of the proximal interphalangeal joint presenting with less than 30% joint involvement, conservative treatment demonstrates positive outcomes [9]. In children with habitual dislocation of the thumb metacarpophalangeal joint, management should be conservative, resisting surgical attempts to tighten the joint and encouraging children to unlearn the habit [144]. For an elderly, low-demand patient with minimal symptoms and posttraumatic ulnar translocation of the carpus, conservative management resulted in satisfactory short-term outcomes [228]. Additionally, conservative treatment is indicated for elbow stiffness due to heterotopic ossification lasting less than six months, utilizing physical therapy and manipulation under anesthesia to restore range of motion [230].

Short-term DIP joint splinting is a safe, simple, and inexpensive modality that reduces pain and improves joint extension [155]. Static progressive orthoses for upper extremity joint stiffness or contracture result in positive outcomes, including increased active range of motion, increased grip strength, improved DASH scores, and improved patient satisfaction [266]. For patients with combined median and ulnar nerve injury, a lumbrical bar splint with the thumb included provides a counterbalance to extrinsic muscles, positioning the thumb in opposition and preventing digit clawing [273]. Management of vascular anomalies of the hand and wrist is dictated by classification, with initial conservative therapy followed by interventional options or surgery for persistent pain, swelling, or functional impairment [218]. A case of avascular necrosis of an adolescent distal radius was managed nonsurgically with activity modification and splinting, resulting in resolution of symptoms and imaging findings [235].

Operative¶

Indications: Surgical management for articular cartilage injuries focuses on removing inflammatory mediators and restoring the osteochondral unit [87]. For hand fractures, the decision not to operate based on radiographs alone, without a meticulous clinical examination, is considered bad clinical practice [242]. Operative treatment improves outcomes for non-geriatric patients with specific fracture patterns but does not improve long-term outcomes for geriatric patients compared to non-operative treatment for distal radius fractures [244]. Conversely, operative treatment of closed isolated distal ulna fractures does not appear to confer a treatment advantage over non-operative treatment [248]. Surgery is indicated for trapeziometacarpal joint fractures and dislocations to restore anatomy and biomechanics, as conservative treatment often yields poor results [16]. For trapeziometacarpal osteoarthritis, surgery is the mainstay of treatment for severely symptomatic cases, generally defined as troublesome painful osteoarthritis restricting thumb and hand function that has not been adequately managed with non-operative treatments [247]. However, it is often assumed that pain will persist indefinitely once surgery is considered, though this may not always be the case; one study reported that 68% of patients referred for consideration of surgery for trapeziometacarpal osteoarthritis did not undergo surgery during the following 2 years [247]. The author has found it sensible to delay surgery for at least 3–6 months after the onset of intolerable pain, or even longer, to determine if the restrictive pain is due to a temporary flare-up [247].

Surgical intervention is reserved for patients with refractory pain in symptomatic DRUJ arthritis, following initial nonsurgical management [33]. For heterotopic ossification, surgical options are necessary if nonoperative management fails to restore elbow function and range of motion after 6 months [230]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop, as few non-unions remain undisplaced, stable, or free of arthritis after ten years [17, 19]. 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 forearm rotation [49]. Indications for scaphoid silicone arthroplasty should be limited, as residual pain and spacer subluxation often lead to secondary reconstructive and salvage procedures [54].

Surgical Approach / Technique: Surgical options for articular cartilage injuries include arthroscopic débridement, bone marrow stimulation, osteochondral autograft transfer, osteochondral allograft transplantation, autologous chondrocyte implantation, and various newer, emerging techniques [87]. For wrist and finger deformity, surgical treatment targets treating joint imbalance to prevent fixed deformity [152]. Prompt and adequate management can prevent joint stiffness and loss of function [28]. For hand fractures, the choice of treatment and the surgery itself should not be delegated to unsupervised junior members of the surgical team or to the occasional hand surgeon [242]. Surgeons should favour the method with which they are most familiar and competent when selecting fixation techniques for hand fractures [242].

External fixation in joint injuries seems to be advantageous, while diaphyseal fractures are rare indications [149]. 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 [150]. If treatment of greater arc wrist injuries is delayed beyond 45 days, the result of satisfactory range of motion is reduced [55]. Prognosis for fracture-dislocation of the radiocarpal joint is guarded, with good results in early-treated patients but potential for late post-traumatic arthritis [52]. Management principles for hypertrophic non-union of a pathological forearm fracture secondary to multiple myeloma remain the same, with stabilisation of the entire bone and early mobilisation being appropriate [210].

For skeletal infection, management should be initiated with broad-spectrum antimicrobial coverage and narrowed down once cultures and sensitivities are obtained [111]. Adequate débridement remains a crucial step in the surgical treatment process [111]. The decision to replace or retain hardware may be contingent on the integrity of both native and artificial structures, distribution of infection, chronicity of infection, and response to previous débridement [111]. Some clinicians have incorporated local antibiotic delivery with products such as antibiotic beads, powder, or cement into their practice [111]. When efforts to treat skeletal infection fail, patients may need long-term antibiotic therapy or more aggressive modalities such as arthrodesis or amputation [111]. Early diagnosis and initiation of treatment are fundamental given the significant morbidity and mortality associated with skeletal infection [111].

Implant Selection: Surgical options such as fusion or arthroplasty for osteoarthritis of the hand and wrist are selected based on the specific joint involved, patient demands, and the risk of complications [1]. The authors recommend intraoperative assessment of articular surfaces rather than preoperative radiographs for selecting the surgical procedure for proximal row carpectomy versus scaphoid excision and intercarpal arthrodesis [3]. Appropriate use of arthroplasty and arthrodesis for affected joints in rheumatoid and osteoarthritic hands and wrists requires careful consideration of the patient's needs [8]. 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 [34].

Alignment / Balancing Strategy: The best results for resection of the distal end of the ulna (Darrach operation) were obtained in patients with minimal bone removal or active bone regeneration [161]. A case demonstrated successful treatment with staged open reduction and internal fixation for combined dislocation of the trapezium and the trapezoid, resulting in full range of motion at 20 months despite arthrosis [162].

Pain Management: The clinical picture of rheumatoid arthritis is best viewed as a combination of systemic symptoms associated with the inflammatory process and articular symptoms related to potentially reversible synovitis and structural damage [271]. The treatment of inflammation in rheumatoid arthritis is medical, and structural lesions often require surgical solutions [271]. Although the effectiveness of antiinflammatory therapies has improved greatly in the last decade, their action is more likely to suppress rather than eliminate structural damage [271]. Most patients with rheumatoid arthritis develop some structural damage during the course of their disease, and more than half may anticipate undergoing a reconstructive procedure [271].

Adjuncts: Selection for perforator free flap coverage of all zones of the mangled upper extremity should be guided by an 'expanded zone' concept that considers soft-tissue prerequisites and functional demands rather than rigid anatomical boundaries [171].

Other Considerations: The procedure for 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 [12]. Modified Viegas capsuloplasty represents a safe and effective joint-preserving surgical option in appropriately selected patients for chronic scapholunate Geissler 3C lesions [35]. Future studies assessing clinical long-term results will likely ensure the place of trapeziometacarpal arthroscopy in the treatment armamentarium for trapeziometacarpal osteoarthritis [46]. 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 [127]. Recent small series have suggested a satisfactory rate of acceptable outcomes for arthroscopic evaluation and treatment of basilar joint arthritis [105]. Osteoarthritis will likely remain the most common indication for basal joint arthroscopy, while chronic pain and inflammation are useful indications for metacarpophalangeal arthroscopy [201]. 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 [215]. The value of non-operative treatments for trapeziometacarpal osteoarthritis remains unclear, and there is no widely agreed or standardized protocol for non-operative treatment [247].

For the SHARC procedure for isolated radiocarpal arthritis, although there are limitations in the total degree of movement, the motion which persists is functional, pain relief has been substantial, and long-term outcomes suggest minimal deterioration [62]. Union was achieved in a relatively short period of time with a nonvascularised bone graft for congenital bilateral pseudarthrosis of the index metacarpal bones [70]. Retrograde drilling is a safe and reasonable treatment option to stimulate healing of the subchondral bone without disruption of the articular cartilage for capitellar osteochondritis dissecans [119].

For heterotopic ossification, surgical excision of ectopic bone and contracture release are the most common surgical options [230]. Many authors suggested that delayed surgical excision, 12 to 24 months from injury to operation, is optimal because maturation of ectopic bone occurs and there is enough radiographic evidence of that maturation [230]. Waiting for the ectopic bone to mature and then performing the surgical excision reduces the incidence of recurrence [230]. However, this delay usually leads to further impairment of elbow function as pain intensity increases, muscular atrophy occurs, and secondary contractures are formed [230]. Many authors have studied early heterotopic ossification excision and suggested that this approach is more beneficial for patients with ectopic bone formation on the elbow [230].

For complex recalcitrant non-unions where conventional grafts may fail due to poor vascularity, specifically for scaphoid non-union, a vascularized bone graft based on the ulnar artery is advocated [231]. The modified Nicoll-graft method is the treatment of choice for gap non-unions of the upper extremity [232]. While spontaneous healing of a proximal pole scaphoid non-union is unusual, it may occur in isolated cases, though non-treatment of such fractures is not advocated [234].

Postoperatively, for thumb ulnar collateral ligament repair using suture anchors and suture tape augmentation, the patient is non-weight-bearing to the upper extremity in a thumb spica splint and sling [250]. The patient undergoes follow-up at 10 to 14 days for wound evaluation and suture removal [250]. After the first visit, the patient is transitioned into a removable spica splint, and physical therapy is started at 2 weeks [250].

In any given patient with rheumatoid arthritis, it is rare to have all joints involved, and frequently only a few joints are affected [271]. Evidence exists indicating that virtually all of the joints that ultimately become involved in a given patient are evident on physical examination during the first year of the disease [271]. The course of rheumatoid arthritis is marked by its persistence, with spontaneous remissions being rare and usually occurring only in the first year [271]. Advances in the reconstructive management of rheumatoid arthritis in the last several decades have been considerable and have virtually eliminated the fear of major crippling problems related to the disease [271]. The appropriate orchestration and selection of surgical interventions for rheumatoid arthritis are both [271].

Hand therapy rehabilitation of postsurgical and nonsurgical management is vital in the recovery of patients with intrinsic dysfunction [273]. For the best functional outcome, therapists and surgeons must work, communicate, and learn from one another to provide comprehensive and patient-centered care for intrinsic muscle dysfunction [273]. Patients must be educated on and throughout all aspects of their care, from conservative treatments to preoperative and postoperative treatments [273]. Physicians, therapists, and especially patients must understand the goals of the treatment plan set forth by the physician, whether it be conservative or surgical [273]. Physicians and therapists must also understand the patient's own personal goals and expectations before a [273]. Trapeziectomy is an effective, simple, and low-cost procedure, and the most common of surgical [1].

Complications¶

Scaphoid Non-Union and Arthritis¶

Long-term follow-up is essential to determine final outcomes, as patients must be monitored until complete union, which often takes several years [18]. In a cohort of forty-seven non-unions, few remained undisplaced, stable, or free of arthritis after ten years [19]. Scaphoid fracture dislocation may result in limited range of movement and loss of grip; however, prompt recognition and early management can achieve a painless wrist despite these functional deficits [40]. Carpal fractures exert a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores one year post-injury [199]. While long-term osteoarthritic changes cannot be predicted following isolated trapezium fracture, early reviews indicate excellent functional results [50]. The natural history of scapholunate ligament injuries remains poorly understood, with uncertainty regarding which specific injuries progress to wrist arthritis [65].

Kienböck’s Disease and Avascular Necrosis¶

The definition of "early stage" precollapsed Kienböck’s disease is not well defined, with some authors classifying Lichtman Stages I, II, and IIIa as early stages [66]. Recent treatment algorithms define early stages as those with an "intact lunate," characterized by a structurally undamaged lunate and no cartilage changes at the midcarpal and radiocarpal joints [66]. In Preiser's disease, outcomes vary by stage: two patients with stage 4 disease achieved "Satisfactory" and "Good" results, whereas one patient with stage 2/3 disease had only a "Fair" result [69]. Following a physeal injury to the base of the first metacarpal, symptoms began to settle and X-rays showed evidence of revascularisation two years post-injury [283].

Surgical Complications and Outcomes¶

Arthrodesis for scaphotrapezio-trapezoid arthritis carries risks of nonunion and adjacent joint arthritis [15]. Distal radioulnar joint arthroplasty improved functional outcomes in both implant groups, though reoperations were frequent [58]. The MatOrtho proximal interphalangeal joint arthroplasty demonstrated 85% survival at a minimum of two-years follow-up [61]. In one series, complications occurred in 32 cases before union, with 27 requiring reoperation [194]. Worse outcomes in revision metacarpophalangeal arthroplasty are associated with a history of MCP dislocations, smoking, and the use of SRA implants [287]. In proximal row carpal fusion for scaphoid non-union, one patient experienced a poor functional result due to pseudarthrosis [255]. In wrist joint fusion for scaphoid non-union, all five patients showed marked local arthritic changes, and three had necrosis of a fragment [255]. Tenosynovial chondromatosis in the hand can recur, with one case requiring six excisions and five recurrences over 22 years [262]. Erroneous treatment of a collateral ligament rupture as an infection can result in severe deformity and extensive soft-tissue calcification [261]. Attritional rupture of finger extensor tendons is a rare complication of nonsurgical management of severe Madelung deformity, caused by mechanical irritation over the dorsal prominence of the subluxated ulnar head [208].

Infected Nonunion¶

Infected nonunion is often associated with severe open fracture, extensive comminution, segmental bone loss, or internal fixation of a comminuted closed fracture [133]. Risk factors include exposed bone devoid of vascularized periosteal coverage for more than six weeks, purulent discharge, positive microbiological culture from the wound, and histological evidence of necrotic bone containing empty lacunae [133]. Treatment and long-term outcomes are commonly complicated by soft-tissue problems including multiple sinuses, osteomyelitis, osteopenia, complex deformities with limb-length discrepancy, and adjacent joint stiffness [133]. Motor and sensory dysfunction of the limb, chronic pain, and biopsychosocial factors may lead to considerable physical, social, financial, and mental impact on patients [133].

Other Considerations¶

The outcome of simultaneous dislocations of the five carpometacarpal joints remains uncertain, with hand and wrist functions maintained but often reduced grip strength [4]. Prompt diagnosis and surgical excision of osteoid osteoma of the scaphoid may prevent irreversible articular damage [7]. The rapid adoption of trapeziometacarpal joint arthroplasty risks turning a common feature of ageing into an expanding surgical market before long-term performance is measured against natural history [269]. The etiology of the carpal boss remains unclear [285]. Careful attention to history and physical examination is required to confirm diagnosis and consider other causes prior to committing to surgery for recalcitrant neuropathies in the upper extremity [284]. In septic arthritis of small joints of the hand, patients requiring arthrodesis or amputation tended to be men in their sixties with comorbidities, an idiopathic cause, and delayed presentation [259].

Recovery¶

Light activity (weeks): The evidence provided does not specify a typical week range for light activities such as desk work, driving, or light ADLs. Additionally, the average time taken for union with the fixator was 9 weeks for external fixation of open proximal ulnar fractures [289].

Full activity (months): The evidence provided does not specify a typical month range for full activity, manual work, sport, or full ROM/strength return.

Complete recovery / outcome plateau (months): The evidence provided does not specify a typical month range for complete recovery or outcome plateau.

Rehabilitation protocol: Immediate repair is generally preferred for thumb metacarpophalangeal joint ligament injury, though delayed repair up to 6 weeks may be possible, with chronic instability and arthrosis being risks of deferring treatment [64]. The author recommends volar capsulodesis to preserve motion for metacarpophalangeal hyperextension deformity associated with trapezial-metacarpal arthritis, though long-term outcomes remain unknown [63].

Functional milestones: Prospective follow-up of over 200 patients for vascularized bone flaps for carpal reconstruction has shown that both radiographic measures and patient-reported outcomes turned out great [13]. Long-term follow-up of targeted muscle reinnervation using the anterior interosseous nerve for symptomatic wrist level neuromas shows reduction of reported pain and improvement of function [38]. Although long term osteoarthritic changes cannot be predicted, the early review of isolated fracture of the trapezium showed an excellent functional result [50]. A four year follow-up of an open fracture of the ulna with bone loss treated by bone transport shows good overall function reflecting the durability of the reconstruction [56]. Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent [58]. 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 for the SHARC procedure [62]. At 6-month follow-up, the patient had complete resolution of symptoms and stable tendon tracking for extensor pollicis longus tendon translocation with a history of thumb polydactyly surgery [219]. The patient was free of pain with essentially normal range of motion at thirty-four months follow-up for dislocation of the triangular bone [293]. Surgical removal of the cartilaginous ridge restored normal joint motion and the patient remained free of symptoms for a locking little finger [296].

Other Considerations: Surgical treatment is usually indicated to restore the anatomy and biomechanics of the trapeziometacarpal joint, as conservative treatment often yields poor results [16]. 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 [42]. Current studies indicate that the use of a pyrolytic carbon implant for proximal pole scaphoid replacement can significantly impact the way scaphoid non-unions are treated, with the goal of improving long term functional outcomes for the person [43]. Further longterm studies are encouraged for total replacement of the distal radioulnar joint [59]. Delayed diagnosis makes closed reduction difficult and was associated with less favorable radiographic outcome for carpometacarpal fracture-dislocations [67]. Swaim is remembered as a complex, dynamic, and imaginative orthopaedic surgeon who made pioneer contributions to the treatment of chronic arthritis and arthritic deformities, and who sought to define the extent of clinical experience pending its enrichment by basic research [68]. In light of the utility of MRI for diagnosing complete tears of the collateral ligaments of the metacarpophalangeal joints, the emphasis for determining appropriate course of treatment remains on history and mechanism of injury, physical examination, and patient disability [71]. The authors describe a series of 75 consecutive joint operations in which finger-joints were arthrodesed by making the opposing joint surfaces concave distally and convex proximally [72]. The metacarpals fused, with good motion and grip strengths at the 6-month follow-up visit for reconstruction of a base of fifth metacarpal tumor using the Dubert procedure [168]. No recurrence of radiocarpal translation was observed at long term follow-up for traumatic radiocarpal translocation [189]. 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 for radial longitudinal deficiency [221]. Follow-up showed no return of symptoms of displacement in either case for luxation of extensor tendons of the hand, but the longest follow-up interval was only 20 months [294]. While degenerative changes may occur, they did not necessarily result in disabling symptoms at the time of follow-up for multiple carpometacarpal dislocations [297]. Florid reactive periostitis can resolve without surgical resection, as demonstrated by the disappearance of pain and radiographic changes over a 2-year follow-up period for bilateral second toe transfers to reconstruct radial longitudinal deficiency [298].

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. [1] (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. [2] (10.1016/j.arthro.2011.03.025)
[L4] The authors recommend intraoperative assessment of articular surfaces rather than preoperative radiographs for selecting the surgical procedure. [3] (10.1016/j.jhsa.2014.03.032)
[L5] The outcome of these injuries remains uncertain, with hand and wrist functions maintained but often reduced grip strength. [4] (10.1016/s0020-1383(02)00098-0)
[L3] The radiological classification does not describe all stages of carpometacarpal joint osteoarthritis accurately enough to permit reliable and consistent communication between clinicians. [6] (10.1016/j.jhsa.2014.09.007)
[Case_report] Prompt diagnosis and surgical excision may prevent irreversible articular damage. [7] (10.1007/s11552-008-9159-2)
[L5] Appropriate use of arthroplasty and arthrodesis for affected joints requires careful consideration of the patient's needs. [8] (10.1016/j.hcl.2010.09.003)
[L4] The literature demonstrated positive outcomes for fractures presenting with less than 30% joint involvement that were managed nonsurgically. [9] (10.1177/15589447241231308)
[L5] Surgical outcomes are best when performed before the patient displays severe joint destruction, fixed contractures, subluxation, or dislocation. [10] (10.1016/j.hcl.2005.08.009)
[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. [11] (10.1177/17531934221137979)
[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. [12] (10.2106/jbjs.16.00007)
[Paper] Prospective follow-up of over 200 patients has shown that both radiographic measures and patient-reported outcomes turned out great. [13] (10.1016/j.jhsa.2026.05.018)
[L5] [14] (10.1007/s11552-007-9068-9)
[L4] Arthrodesis has been the primary procedure described, though outcomes are mixed with risks of nonunion and adjacent joint arthritis. [15] (10.1016/j.hcl.2008.03.002)
[L4] Surgical treatment is usually indicated to restore the anatomy and biomechanics of the trapeziometacarpal joint, as conservative treatment often yields poor results. [16] (10.1177/1753193414554357)
[L4] Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop. [17] (10.2106/00004623-198567030-00013)
[L4] Patients must be followed to complete union, often several years, to determine final outcomes. [18] (10.1007/s11552-010-9264-x)
[L4] Few of the forty-seven non-unions were undisplaced, stable, or free of arthritis after ten years. [19] (10.2106/00004623-198466040-00003)
[L3] Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain. [23] (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. [25] (10.1016/j.jhsa.2024.04.005)
[L5] [26] (10.5435/jaaos-d-21-01031)
[L4] The diagnosis in pediatric cases can be challenging due to presenting symptoms and radiographic findings. [27] (10.1016/j.jhsa.2020.05.002)
[L4] Prompt and adequate management can prevent joint stiffness and loss of function. [28] (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. [29] (10.1007/s11552-010-9304-6)
[Case_report] Diagnosis can be confirmed using physical examination, direct radiography, and magnetic resonance imaging. [30] (10.1007/s11552-007-9045-3)
[L5] Initial management of symptomatic DRUJ arthritis is nonsurgical, with surgery reserved for patients with refractory pain. [33] (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. [34] (10.1177/17531934211017703)
[L4] It represents a safe and effective joint-preserving surgical option in appropriately selected patients. [35] (10.1177/17531934261454878)
[L4] The functional range of motion is important for directing indications for surgery and rehabilitation, and assessing outcome of treatment. [37] (10.1177/1753193414533754)
[L5] Long-term follow-up shows reduction of reported pain and improvement of function. [38] (10.1177/15589447251339506)
[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. [39] (10.1177/1753193409355256)
[L5] Although the range of movement may be limited, with loss of grip, a painless wrist can be achieved through prompt recognition and early management. [40] (10.1016/s0020-1383(97)00020-x)
[Paper] The novel classification system for hamatometacarpal fracture-dislocation can be used to establish guidelines for appropriate treatment. [41] (10.1016/j.injury.2012.02.019)
[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. [42] (10.1177/17531934221137780)
[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. [43] (10.1016/j.jht.2010.09.015)
[L5] Imaging techniques allow better understanding of conditions that affect the shoulder. [44] (10.1197/j.jht.2007.02.002)
[L4] The patient remained pain- and symptom-free at 14 months with full range of motion and no recurrence on MRI. [45] (10.1016/j.jhsg.2020.04.002)
[L5] Future studies assessing clinical long-term results will likely ensure its place in the treatment armamentarium for trapeziometacarpal osteoarthritis. [46] (10.1016/j.hcl.2006.02.006)
[L4] The goal of surgical fixation is a stable reduced joint that will tolerate immediate postoperative range of motion. [47] (10.2106/jbjs.rvw.m.00049)
[L5] [48] (10.1197/j.jht.2007.03.001)
[L5] Although long term osteoarthritic changes cannot be predicted the early review showed an excellent functional result. [50] (10.1016/s0020-1383(97)00169-1)
[L4] Metallic hinged prostheses have been used to restore function in rheumatoid finger joints, with indications including gross joint destruction, dislocation, and persistent deformity. [51] (10.2106/00004623-196143050-00011)
[L4] Prognosis is guarded, with good results in early-treated patients but potential for late post-traumatic arthritis. [52] (10.2106/00004623-197759020-00011)
[L4] The indications for the procedure should be limited, as residual pain and spacer subluxation often lead to secondary reconstructive and salvage procedures. [54] (10.2106/00004623-198567030-00012)
[L4] If treatment is delayed beyond 45 days the result of satisfactory range of motion is reduced. [55] (10.1016/s0020-1383(12)70078-5)
[L5] A four year follow-up is provided and the patient has good overall function reflecting the durability of the reconstruction. [56] (10.1016/s0020-1383(99)00098-4)
[L5] Satisfactory results can be achieved with proper patient selection, meticulous technique, and joint fusion in an appropriate position for the patient's activities and expectations. [57] (10.5435/jaaos-d-15-00033)
[L4] Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. [58] (10.1016/j.jhsa.2022.02.014)
[L4] Further longterm studies are encouraged. [59] (10.1177/15589447241233362)
[Paper] MCP arthroplasty is the procedure of choice at the CMC joint, while arthrodesis is the usual option at the IP level, with the goal of maintaining mobility in as many joints as possible. [60] (10.1016/j.hcl.2010.10.001)
[L4] The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up. [61] (10.1177/1753193415614251)
[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. [62] (10.1016/j.jhsa.2014.06.065)
[L5] The author recommends volar capsulodesis to preserve motion, though long-term outcomes remain unknown. [63] (10.1016/j.jhsa.2011.05.006)
[L5] Immediate repair is generally preferred, though delayed repair up to 6 weeks may be possible, with chronic instability and arthrosis being risks of deferring treatment. [64] (10.1016/j.hcl.2012.05.026)
[L5] The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis. [65] (10.1007/s11552-013-9499-4)
[L5] [66] (10.1177/17531934221146851)
[L4] Delayed diagnosis makes closed reduction difficult and was associated with less favorable radiographic outcome. [67] (10.1177/1558944719852743)
[L5] Swaim is remembered as a complex, dynamic, and imaginative orthopaedic surgeon who made pioneer contributions to the treatment of chronic arthritis and arthritic deformities, and who sought to define the extent of clinical experience pending its enrichment by basic research. [68] (10.2106/00004623-196446060-00026)
[Paper] [69] (10.1016/j.hcl.2006.07.005)
[L4] Union was achieved in a relatively short period of time with a nonvascularised bone graft. [70] (10.1177/1753193408090120)
[L4] In light of this, the emphasis for determining appropriate course of treatment remains on history and mechanism of injury, physical examination, and patient disability. [71] (10.1007/s11552-013-9558-x)
[L4] The authors describe a series of 75 consecutive joint operations in which finger-joints were arthrodesed by making the opposing joint surfaces concave distally and convex proximally. [72] (10.1016/s0020-1383(71)80177-8)
[L4] The techniques presented provide a detailed description of forearm kinematics. [77] (10.1177/17531934221142520)
[L4] When elbow pain is accompanied by musculoskeletal or systemic red flags, clinicians should perform a structured assessment and refer promptly. [78] (10.1016/j.jht.2026.02.009)
[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. [95] (10.1016/j.jhsa.2019.01.019)
[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. [100] (10.5435/00124635-199503000-00005)
[L5] From a mechanical perspective, the metacarpophalangeal joint represents a joint with 5 kinematic degrees of freedom. [101] (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. [103] (10.1016/j.jhsg.2023.08.001)
[L5] The development of a trigger wrist is atypical, with multiple causes for its development. [104] (10.1177/15589447241284303)
[L4] Recent small series have suggested a satisfactory rate of acceptable outcomes for arthroscopic evaluation and treatment of basilar joint arthritis. [105] (10.1016/j.hcl.2011.05.005)
[Case_report] Definitive diagnosis and appropriate management are required for any locking of the MCP joint to prevent fixed flexion contracture and permanent disability. [106] (10.1007/s11552-012-9446-9)
[L5] This article provides evidence that evaluation of upper limb joint function may be performed without the use of instruments and using only clinical means to diagnose in most cases. [107] (10.1016/s0749-0712(03)00029-5)
[L5] Wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, LRTI most closely resembled the intact biomechanics in this cadaveric model. [108] (10.1016/j.jhsa.2019.10.003)
[L3] Associated medical and musculoskeletal conditions are common in patients with ULD, of which cardiac and lower extremity abnormalities are most frequently observed. [109] (10.1016/j.jhsa.2022.05.021)
[Paper] ChatGPT 4.0 technology is not currently able to consistently and reliably provide accurate diagnoses when prompted with radiologic studies of common orthopedic upper extremity pathologies. [110] (10.1177/15589447241298982)
[L4] This case supports the inclusion of metacarpal head osteochondroma in the differential diagnosis of a 'trigger finger.' Advanced imaging is critical for identifying bony prominences causing locking when common etiologies are absent. [115] (10.1016/j.jhsg.2023.03.010)
[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. [116] (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. [119] (10.1016/j.arthro.2011.03.054)
[L5] This study describes the effect of lunate morphology on 3-dimensional carpal kinematics during wrist flexion and extension. [122] (10.1016/j.jhsa.2014.09.019)
[L3] [124] (10.1177/1753193419845290)
[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. [126] (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. [127] (10.1016/j.jhsg.2021.02.003)
[L4] The new Buttazzoni classification system is simple, covers all radial fracture types, and has acceptable reliability comparable to commonly used systems. [131] (10.1007/s11552-009-9163-1)
[L5] [132] (10.1177/15589447211017211)
[L5] [134] (10.5435/jaaos-d-25-00583)
[L4] [135] (10.1016/j.jhsa.2007.11.019)
[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. [136] (10.1007/s11552-013-9517-6)
[L4] [137] (10.1186/s12891-021-04514-z)
[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. [138] (10.1016/j.jhsa.2014.12.001)
[L4] Management should be conservative, resisting surgical attempts to tighten the joint, and encouraging children to unlearn the habit. [144] (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. [145] (10.2106/00004623-198971090-00011)
[L4] Forearm positioning has great implications on daily functioning, as well as strength and skilled use of the hand. [146] (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. [147] (10.2106/00004623-196749040-00009)
[Paper] While diaphyseal fractures are rare indications, external fixation in joint injuries seems to be advantageous. [149] (10.1016/s0020-1383(99)00255-7)
[L4] Fixation is possible up to 8 weeks after injury, though earlier treatment yields better range of motion outcomes. [150] (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. [151] (10.1016/j.jhsg.2023.10.005)
[L5] Additionally, surgical treatment targets treating joint imbalance to prevent fixed deformity. [152] (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. [153] (10.1177/17531934231154158)
[L2] Short-term DIP joint splinting is a safe, simple, inexpensive treatment modality which reduces DIP joint pain and improves joint extension. [155] (10.1016/j.jht.2013.08.004)
[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. [157] (10.1016/j.jhsa.2024.09.005)
[L4] In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques. [159] (10.1007/s11552-010-9265-9)
[L4] The best results were obtained in patients with minimal bone removal or active bone regeneration. [161] (10.2106/00004623-195234040-00016)
[Case_report] This case demonstrates successful treatment with staged open reduction and internal fixation, resulting in full range of motion at 20 months despite arthrosis. [162] (10.1007/s11552-009-9216-5)
[Paper] Conservative management remains an effective treatment strategy, yielding favorable short-term outcomes and rapid return to function. [163] (10.1177/15589447251378682)
[L4] There are different classification systems which were developed with various aims. [166] (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. [167] (10.1007/s11552-010-9273-9)
[L5] The metacarpals fused, with good motion and grip strengths at the 6-month follow-up visit. [168] (10.1177/15589447261469602)
[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. [169] (10.1016/j.jhsa.2013.04.038)
[L5] These classifications help to identify unstable fractures and offer insight into the indications for external skeletal fixation. [170] (10.1016/0020-1383(95)90125-6)
[L5] Selection should be guided by an 'expanded zone' concept that considers soft-tissue prerequisites and functional demands rather than rigid anatomical boundaries. [171] (10.1016/j.jhsg.2024.03.015)
[L5] Our understanding of morphology may lend insight into the biomechanics and disease progression within the DIP joints. [174] (10.1007/s11552-014-9605-2)
[L5] Total joint replacement offers advantages over other surgical treatments, including restoration of thumb length and alignment, good cosmetic results, and faster recovery, though it is technically demanding with a potentially higher complication rate. [176] (10.1530/eor-22-0027)
[L4] The bone-ligament-bone reconstruction displayed physiologic carpal kinematics in the adjacent joints compared with arthrodesis. [178] (10.1016/j.jhsg.2020.11.001)
[L2] We propose a modified classification that is a practical and utilitarian scheme for nomenclature of radial polydactyly and that may assist comparison of treatment outcomes and individual cases. [180] (10.1016/j.jhsa.2007.12.012)
[L5] An ideal classification system for congenital hand differences should incorporate etiology, diagnosis, treatment, and prognosis, be detailed enough to differentiate among various differences but not too cumbersome to be useful, and be widely accepted to facilitate standardized communication. [181] (10.1016/j.hcl.2009.02.002)
[L4] These results may contribute to a better comprehension of the mechanisms underlying wrist joint injuries, the development of preventative measures to lower the risk of injuries, and the best possible design of engineering or rehabilitation devices. [182] (10.3389/fnhum.2023.1193937)
[Letter] The authors argue that a joint registry is necessary to evaluate implant survivorship across multiple surgeons before a randomized controlled trial can be justified, ensuring progress is based on robust data free from bias. [183] (10.1177/17531934211008364)
[L5] Fractures of the fingers are better understood, indications for surgical treatment are more clearly defined, and operative techniques and implants for osteosynthesis are continuing to evolve and improve, though results vary according to fracture type, surgeon experience, and patient compliance. [185] (10.1054/jhsb.2002.0889)
[L3] We advocate the use of the Unified Classification System to guide management of periprosthetic fractures around Motec implants. [186] (10.1177/17531934261419383)
[L4] This review shows that Littler correctly intuited important mathematical relationships of the hand; the functional lengths of the phalanges for the little finger follow a Fibonacci series, while the lengths for the index, long, and ring fingers follow a related pattern called the Littler series. [187] (10.1007/s11552-010-9268-6)
[L4] No recurrence of radiocarpal translation was observed at long term follow-up. [189] (10.1016/j.jhsg.2024.01.001)
[L5] During thumb oppositional motion, internal rotation of the first metacarpal occurred, with the palmar base rotating primarily with respect to the dorsal base. [190] (10.1016/j.jhsa.2017.07.028)
[L4] The quantification of thumb kinematics helps to better understand motor dysfunction in carpal tunnel syndrome, assess the severity of the condition and decide on treatment. 3-D motion analysis is expected to be used both in the assessment of severity of CTS and thumb motor function after treatment. [191] (10.1177/17531934211014700)
[L4] One cannot rely entirely on the existing anatomical classifications of the MN in the carpal tunnel. [192] (10.1016/j.injury.2020.03.024)
[L4] The proposed classification system supplements Wassel's classification by providing clear guidance on surgical methods and required surgeon expertise levels, facilitating treatment decision-making and communication. [193] (10.1177/1753193421995697)
[L2] Complications occurred in 32 cases before union, with 27 requiring reoperation. [194] (10.1016/s0020-1383(01)00128-0)
[L5] The 2020 OMT classification update streamlines terminology and reorganizes categories, such as moving arthrogryposis to a dedicated 'dysplasias – congenital contracture' group, to improve clinical utility and reflect current understanding of limb development and genetics. [195] (10.1177/1753193420964335)
[L1] The definition of metacarpal nonunion remains highly variable and lacks standardization with respect to clinical and radiographic criteria. [196] (10.1016/j.jhsg.2023.04.014)
[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. [199] (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. [200] (10.1016/s0363-5023(11)60022-1)
[L5] Osteoarthritis will likely remain the most common indication for basal joint arthroscopy while chronic pain and inflammation are useful indications for metacarpophalangeal arthroscopy. [201] (10.1016/j.jhsa.2007.02.020)
[L4] With the increased focus on dynamic imaging for wrist motion, it may be possible to derive a standardized protocol for mapping the carpal motion that is clinically applicable and reproducible. [202] (10.1016/j.jhsg.2022.10.001)
[L4] The authors propose a classification system (Type I, II, III) for trans-trapezium carpometacarpal dislocation of the thumb to aid management, suggesting non-operative treatment for stable Type I injuries and surgical fixation for unstable Type II and III injuries. [204] (10.1177/17531934241261628)
[L5] The authors propose a simplified classification system to bring the surgical management of radial polydactyly closer to a unifying approach, aiming to address at least 95% of all cases. [205] (10.1177/17531934261455208)
[L5] [208] (10.5435/00124635-201306000-00007)
[L4] The position of the thumb interphalangeal joint affects movements of the trapeziometacarpal joint and thenar muscle activity during opposition. [209] (10.1177/17531934211065879)
[Case_report] Management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate. [210] (10.1186/1749-799x-5-26)
[L5] Follow-up at 6 weeks revealed a complete recovery of nerve and hand function. [212] (10.1016/s0020-1383(99)00283-1)
[L4] The functional and anatomical results in all children at a mean follow up of 4 years were excellent. [214] (10.1016/s0020-1383(00)00057-7)
[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. [215] (10.1177/17531934221122987)
[L4] Conservative treatment is the initial approach, but surgical decompression is indicated if these measures fail. [216] (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. [217] (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. [218] (10.5435/jaaos-22-06-352)
[L5] At 6-month follow-up, the patient had complete resolution of symptoms and stable tendon tracking. [219] (10.1016/j.jhsg.2026.101060)
[L4] Radiological findings support good bone tolerance with signs of progressive integration, despite moderate erosion and bone remodeling in some cases. [220] (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. [221] (10.5435/00124635-200701000-00005)
[L2] MRI alters the treatment of hand, wrist, and elbow conditions in less than 1 in 5 patients. [222] (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. [223] (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. [225] (10.1016/j.jhsa.2021.02.017)
[L5] Vascularized bone graft is recommended when osteonecrosis of the proximal pole is evident on MRI. [226] (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. [228] (10.1016/j.jhsg.2021.10.002)
[L5] [229] (10.5435/jaaos-d-21-00981)
[L4] [230] (10.3390/life13122358)
[L4] This technique is advocated for complex recalcitrant non-unions where conventional grafts may fail due to poor vascularity. [231] (10.2106/00004623-199072010-00015)
[L4] The authors state this method is their treatment of choice for gap non-unions of the upper extremity. [232] (10.2106/00004623-198163020-00007)
[Case_report] The early radiographic results of this reconstruction are promising. [233] (10.1007/s11552-011-9361-5)
[L4] The authors note that while this outcome is unusual, it may occur in isolated cases, though they do not advocate for non-treatment of such fractures. [234] (10.1007/s11552-011-9328-6)
[L4] The patient was managed nonsurgically with activity modification and splinting, resulting in resolution of symptoms and imaging findings. [235] (10.1016/j.jhsg.2022.12.009)
[L5] Although clinical improvement was limited at 15 months, magnetic resonance imaging demonstrated preservation of capitate morphology and reduced signal abnormalities. [236] (10.1016/j.jhsg.2026.101093)
[L5] Standard radiographs provide between 53% and 90% sensitivity, while CT offers 94% specificity and 97% accuracy. [238] (10.1016/j.jhsa.2013.06.004)
[Paper] [240] (10.2106/jbjs.25.01568)
[Paper] MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers. [241] (10.1016/s0363-5023(10)60085-8)
[L5] [242] (10.1177/1753193420928820)
[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. [243] (10.1016/j.otsr.2021.103153)
[L4] [245] (10.1016/j.jhsa.2013.10.012)
[L5] This review provides an overview of current diagnostic imaging technologies and their clinical application for common conditions of the hand, wrist, and forearm, while also considering evolving and future imaging technologies. [246] (10.1197/j.jht.2007.03.002)
[L5] [247] (10.1177/1753193420970343)
[L4] Operative treatment of closed isolated distal ulna fractures does not appear to confer a treatment advantage when compared to non-operative treatment. [248] (10.1007/s11552-011-9363-3)
[L4] Where a pseudoepiphysis is seen on the radiographs of a healthy asymptomatic child, the patient and their family should simply be reassured. [249] (10.1177/1753193411436295)
[L5] [250] (10.1016/j.eats.2025.103957)
[L4] [252] (10.2106/jbjs.rvw.m.00074)
[L4] MRI determination of PIN position is reliable and consistent with prior cadaveric study. [257] (10.1016/j.arthro.2020.12.118)
[L5] The use of PCD-CT is likely to revolutionize many fields of medical imaging, but the improvement in image resolution and versatility would especially benefit musculoskeletal imaging. [258] (10.1177/17531934221132692)
[L3] Patients requiring arthrodesis or amputation tended to be men in their sixties with comorbidities, an idiopathic cause, and delayed presentation. [259] (10.1016/s0363-5023(10)60129-3)
[L4] The study found that MRI identified the cartilaginous configuration precisely, which assisted in choosing the correct site to perform osteotomies and eliminated the need for secondary operations. [260] (10.1177/1753193420983213)
[L4] [261] (10.2106/00004623-196749020-00009)
[L4] [262] (10.2106/00004623-197961060-00016)
[L1] [266] (10.1007/s11552-011-9380-2)
[L5] Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions. [268] (10.5435/jaaos-d-15-00170)
[L5] The rapid adoption of trapeziometacarpal joint (TMJ) arthroplasty should be met with caution, as it risks turning a common feature of ageing into an expanding surgical market before long-term performance is measured against natural history. [269] (10.1177/17531934261467231)
[L4] Radiographic reduction was maintained in all patients, and complications were infrequent and manageable. [270] (10.1177/15589447261469607)
[L5] [271] (10.1016/j.hcl.2010.10.007)
[L3] [272] (10.1177/1558944719855443)
[L5] [273] (10.1016/j.hcl.2011.09.001)
[Paper] Only in the limited group of cases with a clinical, radiographical, or a high index of suspicion of an occult or difficult to visualise fracture, extensive radiographic procedures should be performed, in order to secure the best outcome for all. [274] (10.1016/s0020-1383(98)00220-4)
[L5] Radiographic development of trapeziometacarpal arthrosis is an expected part of human aging, although clinically significant, functionally limiting trapeziometacarpal arthrosis is less common, and its development may be unrelated to hand use. [277] (10.1016/j.jhsa.2015.04.038)
[L5] [278] (10.2106/jbjs.rvw.n.00053)
[L5] [280] (10.1177/1753193413516246)
[L4] MRI and ultrasound are the preeminent diagnostic tools. [281] (10.1197/j.jht.2007.10.019)
[L5] Two years after the original injury, symptoms were beginning to settle down and X-rays showed evidence of revascularisation. [283] (10.1016/s0020-1383(01)00033-x)
[L4] Careful attention to history and physical examination is required to confirm diagnosis and consider other causes prior to committing to surgery. [284] (10.1016/j.jhsg.2023.03.002)
[L4] The etiology of the carpal boss remains unclear. [285] (10.1016/j.jhsa.2008.08.025)
[L3] Worse outcomes are seen in patients with a history of MCP dislocations, smokers, and SRA implants. [287] (10.1016/j.jhsa.2014.06.064)
[L3] The average time taken for union with the fixator was 9 weeks. [289] (10.1016/s0020-1383(98)00235-6)
[L5] [290] (10.2106/00004623-197254080-00003)
[L4] The patient was free of pain with essentially normal range of motion at thirty-four months follow-up. [293] (10.2106/00004623-198163060-00021)
[L4] Follow-up showed no return of symptoms of displacement in either case, but the longest follow-up interval was only 20 months. [294] (10.1016/s0020-1383(70)80032-8)
[L4] Surgical removal of the cartilaginous ridge restored normal joint motion and the patient remained free of symptoms. [296] (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. [297] (10.2106/00004623-197961060-00018)
[Case_report] Florid reactive periostitis can resolve without surgical resection, as demonstrated by the disappearance of pain and radiographic changes over a 2-year follow-up period. [298] (10.1177/1753193418773030)

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Bones and Joints

Overview¶

Anatomy & Pathophysiology¶

Bony Anatomy and Skeletal Development¶

Joint Mechanics and Kinematics¶

Muscular Anatomy and Function¶

Classification¶

General Principles and Reliability¶

Specific Joint and Bone Classifications¶

Tumour Staging¶

Clinical Presentation¶

History and General Evaluation¶

Tumor-Specific Symptoms¶

Diagnostic Challenges and Red Flags¶

Specific Joint Pathologies¶

Imaging and Diagnostic Modalities¶

Investigations¶

Clinical Examination¶

Plain radiography¶

Computed Tomography (CT)¶

Magnetic Resonance Imaging (MRI)¶

Ultrasonography¶

Other Considerations¶

Treatment¶

Non-Operative¶

Operative¶

Complications¶

Scaphoid Non-Union and Arthritis¶

Kienböck’s Disease and Avascular Necrosis¶

Surgical Complications and Outcomes¶

Infected Nonunion¶

Other Considerations¶

Recovery¶

Key Evidence¶

See Also¶

References¶