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Bones and Joints

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

Overview

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

For pediatric upper extremity bone lengthening, success is commonly defined by radiographic lengthening, joint motion, and patient satisfaction rather than validated outcome measures [4]. This procedure is associated with a high complication rate [4]. In the adult hand, the functional range of motion of finger joints is important for directing surgical indications, rehabilitation, and assessing treatment outcomes [15].

Joint-preserving options include modified Viegas capsuloplasty for chronic scapholunate Geissler 3C lesions, which represents a safe and effective option in appropriately selected patients [14]. For scaphoid excision with intercarpal arthrodesis versus proximal row carpectomy, intraoperative assessment of articular surfaces is recommended over preoperative radiographs for selection [18]. The one-bone forearm reconstructive procedure is indicated only if instability and bone loss are irreparable by bone-grafting or other reconstructive procedures and there is no chance of restoring forearm rotation [20].

Elbow fracture-dislocations, such as Monteggia and transolecranon injuries, require surgical fixation aimed at a stable reduced joint that tolerates immediate postoperative range of motion [58]. Metallic hinged prostheses restore function in rheumatoid finger joints with indications including gross joint destruction, dislocation, and persistent deformity [61]. Tenolysis is unsuccessful when performed with poor indications, incomplete tendon freeing, or in association with complex orthopaedic procedures that do not permit early postoperative active motion [67].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Forearm kinematics are detailed via four-dimensional computed tomography [31], while video motion capture identifies three distinct movement phases of the hand during lateral and pulp pinches [60]. The metacarpophalangeal joint possesses five kinematic degrees of freedom mechanically [42]. Lunate morphology influences the three-dimensional kinematics of the carpus during wrist flexion and extension [52]. Fractures of the distal radius compromise wrist biomechanical integrity, limiting range of motion and reducing hand muscle strength [54]. Incongruous radiocarpal joints are well tolerated due to wrist biomechanics, specifically the midcarpal joint’s role in the dart-throwing motion; consequently, the necessity of aggressive treatment for radiocarpal stepoffs larger than 1 mm is questioned [82].

Forearm and Wrist Biomechanics

Forearm shortening of 3 or 4 cm results in near-complete loss of flexor digitorum profundus (FDP) simulated muscle force and tip-to-palm force in wrist-neutral and wrist-extension positions, respectively [74]. The authors acknowledge that their biomechanical model investigating forearm shortening effects on finger flexion is an initial attempt, noting that an in vivo model incorporating active muscle contraction would be ideal [59]. Wrist biomechanics are significantly altered following trapeziectomy; among reconstructions tested in a cadaveric model, ligament reconstruction and tendon interposition (LRTI) most closely resembled intact wrist biomechanics [45].

Hand and Thumb Biomechanics

Three-dimensional analysis of internal forces in thumb joints during pinch and grasp provides data on tensile forces in functioning tendons, contact and shear forces, and constraining moments acting on the joints [51]. Finger forces are more hampered while gripping objects with smaller circumferences than large ones following flexor digitorum superficialis tendon transfer [56]. The extensor pollicis brevis tendon transfer can reconstruct thumb extension and abduction functions without requiring a pulley [73]. The inter-metacarpal distance method is currently the most reliable tool for measuring thumb abduction in adults with thumb carpometacarpal joint pain [75].

Surgical Principles and Assessment

A thorough understanding of biomechanical principles and neurological pathways is necessary for hand surgeons [33]. Understanding foundational principles of anatomy and kinematics is a critical component in the treatment algorithm for fractures of the carpus and hand [79]. Both plate and intramedullary screw fixation for extra-articular metacarpal base fractures surpass expected physiologic loading during hand use, making either approach biomechanically acceptable depending on clinical context [40]. Ideally, digits need sensation and freedom of motion to enable effective use, and effective surgery restores biomechanical motions for optimum patient use [63]. Forearm positioning has great implications on daily functioning, as well as strength and skilled use of the hand [66]. Limitations in quantifying joint motion to exact precision persist even with in-person assessment [72].

Classification

Radiological General: Radiological classification of carpometacarpal joint osteoarthritis does not accurately describe all stages, preventing reliable and consistent communication between clinicians [8]. There is a lack of a generally accepted classification system for chronic skeletal disorders of the forearm in adults [11]. Various radiological measurements and classifications are used to evaluate the trapeziometacarpal joint [17].

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

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

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

Buttazzoni: The Buttazzoni classification system for distal radial fractures in adults is simple, covers all radial fracture types, and has acceptable reliability comparable to commonly used systems [57].

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

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

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

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

Upper Limb Orthoses: Different classification systems for upper limb orthoses were developed with various aims [80].

Clinical Presentation

The clinical evaluation of hand and wrist pathology requires a structured approach to differentiate between degenerative, congenital, traumatic, and inflammatory etiologies. Surgical decision-making for osteoarthritis, including fusion or arthroplasty, depends on the specific joint involved, patient demands, and complication risks [1]. For rheumatoid and osteoarthritic hands, appropriate use of arthroplasty and arthrodesis requires careful consideration of individual patient needs [3]. Initial management of symptomatic distal radioulnar joint (DRUJ) arthritis is nonsurgical, reserving surgery for refractory pain [12]. Conversely, thumb arthritis diagnosis involves reviewing pathoanatomy, physical examination, and imaging to guide treatment for early and advanced disease [30].

Red-flag patterns necessitate immediate action; elbow pain accompanied by musculoskeletal or systemic red flags requires structured assessment and prompt referral [32]. In patients with nonspecific wrist pain, clinicians must exercise caution when ascribing symptoms to anatomical variations on radiographs [6]. Similarly, in musculoskeletal syndromes presenting with wrist pain, careful examination of both wrists and radiographic evaluation for carpal anomalies is essential [38]. Disorders of the DRUJ are a common source of ulnar-sided wrist pain, where increased understanding of anatomy and pathology facilitates accurate diagnosis [41].

Congenital and developmental anomalies present distinct diagnostic challenges. Objective radiographic data aids preliminary diagnosis of Blauth Type III thumb hypoplasia, though in-person physical examination remains necessary [7]. Congenital absence of the flexor pollicis longus tendon without associated thumb hypoplasia can be confirmed via physical examination, direct radiography, and magnetic resonance imaging [10]. Diagnosis of bizarre parosteal osteochondromatous proliferation (Nora lesion) in pediatric phalanges is challenging due to overlapping symptoms and radiographic findings [35].

Tumors and chronic disorders require specific diagnostic modalities. Osteoid osteoma should be considered in the differential for painful bony tumors in the hand, particularly in pediatric and adult patients, as atypical features and locations complicate work-up [36]. Prompt diagnosis and surgical excision of scaphoid osteoid osteoma may prevent irreversible articular damage [9]. Chronic skeletal disorders of the forearm involve both bone and soft-tissue structures, contributing to treatment complexity and a lack of accepted classification systems [11]. Differentiating tenosynovitis with psammomatous calcification from intra-articular lesions is critical, especially in atypical presentations [43].

Acute injuries and functional assessments rely on thorough physical examination and imaging. Accurate diagnosis of finger metacarpophalangeal joint injuries in athletes requires understanding all potential diagnoses to ensure safe, early return to play [34]. Management of hand and carpal fractures and dislocations is predicated on thorough examination and appropriate imaging to limit stiffness while preserving mobility [39]. Prompt management of toe extensor tendon anatomy issues prevents joint stiffness and loss of function [37]. Finally, a succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis [2].

Investigations

Plain radiography: Plain radiography provides the most basic and useful information for shoulder diagnostic imaging [77]. For hand tumors, radiographs are mandatory alongside ultrasound, with MRI reserved for atypical findings such as bone extension of a soft tissue lesion, osteolysis, or size greater than 3 cm [110]. In thumb hypoplasia, objective radiographic data may aid preliminary diagnosis and treatment recommendations for Blauth Type III, although in-person physical examination remains necessary [7]. Radiological findings support good bone tolerance with signs of progressive integration for spherical pyrocarbon HAPY metacarpophalangeal interposition arthroplasty, despite moderate erosion and bone remodeling in some cases [97]. Early radiographic results of triquetral autograft reconstruction of the lunate fossa of the distal radius are promising [105]. Standard radiographs provide between 53% and 90% sensitivity for hook of hamate fractures [106]. Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain [6]. The radiological classification of carpometacarpal joint osteoarthritis does not describe all stages accurately enough to permit reliable and consistent communication between clinicians [8]. Delayed diagnosis of carpometacarpal fracture-dislocations makes closed reduction difficult and is associated with less favorable radiographic outcomes [27].

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

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

Bone scan: Advanced imaging, including bone scintigraphy, is helpful to confirm the diagnosis of thumb metacarpal-trapezoid impingement after trapeziectomy and basal joint soft tissue arthroplasty [101].

Other Considerations: Surgical options for hand and wrist osteoarthritis, such as fusion or arthroplasty, are selected based on the specific joint involved, patient demands, and the risk of complications [1]. A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis [2].

Treatment

Non-Operative Management

Initial management of symptomatic distal radioulnar joint (DRUJ) arthritis is nonsurgical, with surgery reserved for patients with refractory pain [12]. Nonoperative therapy is recommended as the initial treatment course for scaphotrapezio-trapezoid arthritis [68]. Nonoperative options are commonly used as first-line treatment for tenosynovitis of the hand and wrist, though questions remain regarding when to advance to operative intervention [95]. Conservative treatment is the initial approach for extensor indicis proprius syndrome, but surgical decompression is indicated if conservative measures fail [94]. 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 [96]. Thumb carpometacarpal (CMC) joint arthritis is an expected part of aging, and many patients may become asymptomatic or minimally symptomatic; therefore, nonoperative care including therapy should be offered as first-line treatment as patients may find relief and never proceed with surgery [100]. Habitual dislocation of the thumb metacarpophalangeal joint in children should be managed conservatively by resisting surgical attempts to tighten the joint and encouraging children to unlearn the habit [64]. Conservative management resulted in a satisfactory short-term outcome for an elderly, low-demand patient with minimal symptoms and posttraumatic ulnar translocation of the carpus [103].

Operative

Indications: Surgical options such as fusion or arthroplasty are selected based on the specific joint involved, patient demands, and the risk of complications [1]. Appropriate use of arthroplasty and arthrodesis for affected joints requires careful consideration of the patient's needs [3]. The functional range of motion is important for directing indications for surgery and rehabilitation, and assessing outcome of treatment [15]. Surgical treatment targets treating joint imbalance to prevent fixed deformity in the management of wrist and finger deformity [71]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [5]. The prognosis for fracture-dislocation of the radiocarpal joint is guarded, with good results in early-treated patients but potential for late post-traumatic arthritis [21]. The one-bone forearm procedure is indicated only if instability and bone loss are irreparable by bone-grafting or other reconstructive procedures and there is no chance of restoring rotation of the forearm [20].

Surgical Approach / Technique: Treatment of the arthritic wrist requires a diversity of treatment options due to the complex integrated system of joints, rather than a single effective treatment [47]. The authors recommend intraoperative assessment of articular surfaces rather than preoperative radiographs for selecting between proximal row carpectomy and scaphoid excision with intercarpal arthrodesis [18]. Retrograde drilling is a safe and reasonable treatment option to stimulate healing of the subchondral bone in capitellar osteochondritis dissecans without disruption of the articular cartilage [49]. Management principles for hypertrophic non-union of a pathological forearm fracture secondary to multiple myeloma include stabilization of the entire bone and early mobilization [90]. Fixation of condylar fractures of the proximal and middle phalanges is possible up to 8 weeks after injury, though earlier treatment yields better range of motion outcomes [69]. Vascularized bone graft based on the ulnar artery is advocated for complex recalcitrant scaphoid non-unions where conventional grafts may fail due to poor vascularity [104]. A modified Viegas capsuloplasty represents a safe and effective joint-preserving surgical option for chronic scapholunate Geissler 3C lesions in appropriately selected patients [14].

Implant Selection: Arthroplasty in the hand provides generally good pain relief, but there are high rates of deformity recurrence and complications depending on the implant type and joint involved [13]. The indications for scaphoid silicone arthroplasty should be limited, as residual pain and spacer subluxation often lead to secondary reconstructive and salvage procedures [23]. Recent small series have suggested a satisfactory rate of acceptable outcomes for arthroscopic evaluation and treatment of basilar joint arthritis [44]. A systematic review provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis, with some interventions showing moderate-to-large superior effects compared with others [55].

Other Considerations: Bone lengthening in the pediatric upper extremity is associated with a high complication rate, and success is commonly defined by radiographic lengthening, joint motion, and patient satisfaction rather than validated outcome measures [4]. 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 [93]. The prognosis for fractures and dislocations of the base of the thumb metacarpal depends on the quality of the restoration of the mobility of the trapeziometacarpal joint [22].

Complications

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

Implant Failure and Reoperation: Distal radioulnar joint arthroplasty is associated with frequent reoperations [24]. The survival of MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up [25].

Post-Traumatic and Degenerative Sequelae: Joint chondrolysis requires a succinct set of standardized clinical criteria to guide differential diagnosis [2]. Bone lengthening in the pediatric upper extremity is associated with a high complication rate [4]. Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop [5]. The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis [85]. Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after injury [87]. Long-term outcomes for pelvic ring injuries are complicated by posterior pelvic pain and are largely multifactorial [83].

Nerve Repair Outcomes: No adverse events or revisions were reported with the utilization of processed nerve allografts for large gap nerve discontinuities [91]. No adverse events or revisions were reported when using processed nerve allografts to repair nerve injuries greater than 4cm for the return of critical function in the upper extremity [92].

Other Considerations: Prompt diagnosis and surgical excision of osteoid osteoma of the scaphoid may prevent irreversible articular damage [9]. Mild interphalangeal joint deformity may persist without functional impairment after surgical correction of floating thumb duplication [115]. Long-term outcomes for volar capsulodesis in metacarpophalangeal hyperextension deformity associated with trapeziometacarpal arthritis remain unknown [26].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or return to desk work.

Full activity (months): Evidence does not specify a month range for full activity or manual work.

Complete recovery / outcome plateau (months): Long-term outcomes stabilize over extended periods, with specific milestones varying by pathology. For scaphoid non-union, osteoarthritis is likely to develop [5], and few of forty-seven non-unions remained undisplaced, stable, or free of arthritis after ten years [29]. In skeletally mature subjects, the scaphoid articular surface remodels to restore normal architecture by 3 years [116]. For radiocarpal fracture-dislocations, the prognosis is guarded with potential for late post-traumatic arthritis [21], though no recurrence of radiocarpal translation was observed at long-term follow-up after successful treatment of traumatic translocation [86].

Rehabilitation protocol: Specific rehabilitation protocols, immobilisation durations, or weight-bearing progressions are not detailed in the provided evidence.

Functional milestones: Functional outcomes vary by intervention. Reverse wedge osteotomy for Madelung’s deformity provides convincing clinical and radiological results, with dorsal flattening hoped to protect against extensor tendon tear long-term [19]. Pyrolytic carbon implants for proximal pole replacement aim to improve long-term functional outcomes in scaphoid non-unions [16]. The SHARC procedure yields substantial pain relief and functional motion, with long-term follow-up suggesting minimal deterioration [84]. Distal radioulnar joint arthroplasty improved functional outcomes in both implant groups, though reoperations were frequent [24]. The MatOrtho proximal interphalangeal joint arthroplasty demonstrated 85% survival at a minimum of 2-years follow-up [25].

Other Considerations: Prognosis for thumb base fracture-dislocations depends on the quality of trapeziometacarpal joint mobility restoration [22]. Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis likely leads to degeneration progression, whereas recognition may prevent or delay it [121]. Delayed diagnosis of carpometacarpal fracture-dislocations makes closed reduction difficult and associates with less favorable radiographic outcomes [27]. While degenerative changes may follow multiple carpometacarpal dislocations, they do not necessarily cause disabling symptoms at follow-up [120]. Volar capsulodesis is recommended to preserve motion in metacarpophalangeal hyperextension deformity associated with trapezial-metacarpal arthritis, though long-term outcomes remain unknown [26]. Soft tissue reconstructions alone are unlikely to adequately correct or maintain correction in rheumatoid thumb; joint procedures are preferred [89]. For radial longitudinal deficiency, the child’s overall health and deformity severity guide long-term treatment aimed at realignment and functional thumb provision [98]. Union was achieved rapidly with nonvascularised bone graft for congenital bilateral pseudarthrosis of the index metacarpals [117]. Patients remained pain-free with essentially normal range of motion at 34 months after triangular bone dislocation [118]. Surgical removal of a cartilaginous ridge restored normal joint motion and symptom freedom in locking little finger cases [119].

Key Evidence

  • [L5] Surgical options such as fusion or arthroplasty are selected based on the specific joint involved, patient demands, and the risk of complications. (10.1016/j.jht.2022.01.001)
  • [L4] A succinct set of standardized clinical criteria is necessary to guide the differential diagnosis of joint chondrolysis. (10.1016/j.arthro.2011.03.025)
  • [L5] Appropriate use of arthroplasty and arthrodesis for affected joints requires careful consideration of the patient's needs. (10.1016/j.hcl.2010.09.003)
  • [L5] The procedure is associated with a high complication rate, and success is commonly defined by radiographic lengthening, joint motion, and patient satisfaction rather than validated outcome measures. (10.2106/jbjs.16.00007)
  • [L4] Patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop. (10.2106/00004623-198567030-00013)
  • [L3] Clinicians should be careful ascribing symptoms to anatomical variations on radiographs in patients with nonspecific wrist pain. (10.1016/j.jhsa.2017.02.002)
  • [L3] While in-person physical examination remains necessary, objective radiographic data may aid in preliminary diagnosis and treatment recommendations. (10.1016/j.jhsa.2024.04.005)
  • [L3] The radiological classification does not describe all stages of carpometacarpal joint osteoarthritis accurately enough to permit reliable and consistent communication between clinicians. (10.1016/j.jhsa.2014.09.007)
  • [Case_report] Prompt diagnosis and surgical excision may prevent irreversible articular damage. (10.1007/s11552-008-9159-2)
  • [Case_report] Diagnosis can be confirmed using physical examination, direct radiography, and magnetic resonance imaging. (10.1007/s11552-007-9045-3)
  • [L5] Initial management of symptomatic DRUJ arthritis is nonsurgical, with surgery reserved for patients with refractory pain. (10.5435/00124635-201210000-00002)
  • [L4] The review describes various arthroplasty possibilities, indications, and surgical techniques for hand joints, noting that while pain relief is generally good, there are high rates of deformity recurrence and complications depending on the implant type and joint involved. (10.1177/17531934211017703)
  • [L4] It represents a safe and effective joint-preserving surgical option in appropriately selected patients. (10.1177/17531934261454878)
  • [L4] The functional range of motion is important for directing indications for surgery and rehabilitation, and assessing outcome of treatment. (10.1177/1753193414533754)
  • [L4] While long-term research is still required, current studies indicate that the use of this implant can significantly impact on the way scaphoid non-unions are treated, with the goal of improving long term functional outcomes for the person. (10.1016/j.jht.2010.09.015)
  • [L5] This review provides an overview of different radiological views described for the thumb, emphasizing their historical origin and positioning, and describes various measurements and classifications used to evaluate the trapeziometacarpal joint. (10.1177/17531934221137979)
  • [L4] The authors recommend intraoperative assessment of articular surfaces rather than preoperative radiographs for selecting the surgical procedure. (10.1016/j.jhsa.2014.03.032)
  • [Paper] Clinical and radiological results are convincing, with the flattening of the dorsal aspect of the wrist hoped to provide long-term protection against extensor tendon tear. (10.1016/j.otsr.2013.03.007)
  • [L4] Prognosis is guarded, with good results in early-treated patients but potential for late post-traumatic arthritis. (10.2106/00004623-197759020-00011)
  • [L4] The prognosis depends on the quality of the restoration of the mobility of the trapeziometacarpal joint. (10.1177/1753193414554357)
  • [L4] The indications for the procedure should be limited, as residual pain and spacer subluxation often lead to secondary reconstructive and salvage procedures. (10.2106/00004623-198567030-00012)
  • [L4] Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. (10.1016/j.jhsa.2022.02.014)
  • [L4] The survival of the MatOrtho proximal interphalangeal joint arthroplasty was 85% at a minimum of 2-years follow-up. (10.1177/1753193415614251)
  • [L5] The author recommends volar capsulodesis to preserve motion, though long-term outcomes remain unknown. (10.1016/j.jhsa.2011.05.006)
  • [L4] Delayed diagnosis makes closed reduction difficult and was associated with less favorable radiographic outcome. (10.1177/1558944719852743)
  • [L4] Few of the forty-seven non-unions were undisplaced, stable, or free of arthritis after ten years. (10.2106/00004623-198466040-00003)
  • [Paper] This issue of Hand Clinics provides a review of the pathoanatomy, physical examination, and imaging options for the diagnosis of thumb arthritis, followed by an exploration of treatment options for early and advanced disease. (10.1016/j.hcl.2008.03.009)
  • [L4] The techniques presented provide a detailed description of forearm kinematics. (10.1177/17531934221142520)
  • [L4] When elbow pain is accompanied by musculoskeletal or systemic red flags, clinicians should perform a structured assessment and refer promptly. (10.1016/j.jht.2026.02.009)
  • [L5] A thorough understanding of biomechanical principles and neurological pathways is necessary for the hand surgeon. (10.1177/17531934261434453)
  • [L5] Accurate diagnosis and treatment of finger metacarpophalangeal joint injuries in athletes begins with an understanding of all potential diagnoses, allowing for safe and early return to play. (10.5435/jaaos-d-21-01031)
  • [L4] The diagnosis in pediatric cases can be challenging due to presenting symptoms and radiographic findings. (10.1016/j.jhsa.2020.05.002)
  • [L4] Osteoid osteoma should be considered in the differential diagnosis for painful bony tumors in the hand, particularly in pediatric and adult patients, as it can present with atypical features and locations making work-up and diagnosis challenging. (10.1016/j.jhsa.2019.01.019)
  • [L4] Prompt and adequate management can prevent joint stiffness and loss of function. (10.1177/1753193420936612)
  • [Case_report] In patients with musculoskeletal syndromes who present with wrist pain, it is important to carefully examine both wrists and evaluate the radiographic studies to determine if carpal anomalies may be contributing to their wrist pain. (10.1007/s11552-010-9304-6)
  • [L5] Both fixation methods surpassed expected physiologic loading during hand use, indicating that either approach may be biomechanically acceptable depending on the clinical context. (10.1016/j.jhsg.2025.100897)
  • [L5] Disorders of the distal radioulnar joint are a common source of ulnar-sided wrist pain, but increased understanding of anatomy and pathology has facilitated accurate diagnosis and successful treatment in most cases. (10.5435/00124635-199503000-00005)
  • [L5] From a mechanical perspective, the metacarpophalangeal joint represents a joint with 5 kinematic degrees of freedom. (10.1016/j.jhsa.2008.10.004)
  • [Case_report] This case highlights the importance of differentiating tenosynovitis with psammomatous calcification from intra-articular lesions, particularly in atypical presentations, and demonstrates the effectiveness of surgical intervention in resolving symptoms. (10.1016/j.jhsg.2023.08.001)
  • [L4] Recent small series have suggested a satisfactory rate of acceptable outcomes for arthroscopic evaluation and treatment of basilar joint arthritis. (10.1016/j.hcl.2011.05.005)
  • [L5] Wrist biomechanics were significantly altered following trapeziectomy, and of the reconstructions tested, LRTI most closely resembled the intact biomechanics in this cadaveric model. (10.1016/j.jhsa.2019.10.003)
  • [L4] The adapted AO classification for hand fractures demonstrated good inter-observer agreement for bone identification, substantial agreement for bone segment coding, and moderate agreement for fracture type. (10.1177/1753193409355256)
  • [Paper] Treatment of the arthritic wrist is fascinating and challenging, requiring a diversity of treatment options due to the complex integrated system of joints, rather than a single effective treatment. (10.1016/j.hcl.2005.08.013)
  • [L2] The authors present a new, reliable radiographic classification system for synpolydactyly that will allow improved communication between clinicians and serve as a foundation for future investigations. (10.1177/1753193415598281)
  • [L4] This technique is a safe and reasonable treatment option to stimulate healing of the subchondral bone without disruption of the articular cartilage. (10.1016/j.arthro.2011.03.054)
  • [Paper] The novel classification system for hamatometacarpal fracture-dislocation can be used to establish guidelines for appropriate treatment. (10.1016/j.injury.2012.02.019)
  • [L5] This three-dimensional analysis of the internal forces in the thumb joints during pinch and grasp provides new information concerning the tensile forces in functioning tendons, the contact and shear forces, and the constraining moments acting on the joints. (10.2106/00004623-198769070-00033)
  • [L5] This study describes the effect of lunate morphology on 3-dimensional carpal kinematics during wrist flexion and extension. (10.1016/j.jhsa.2014.09.019)
  • [L3] These results supported the initial hypothesis that a fracture of the distal radius interferes with the biomechanical integrity of the wrist, limiting range of motion and affecting hand muscle strength. (10.1177/1758998315574352)
  • [L1] This systematic review provided evidence of the efficacy of various surgical interventions for trapeziometacarpal osteoarthritis, with some interventions showing moderate-to-large superior effects compared with others. (10.1016/j.jhsg.2021.02.003)
  • [L4] Finger forces are more hampered while gripping objects with smaller circumferences than large ones. (10.1177/17531934211061220)
  • [L4] The new Buttazzoni classification system is simple, covers all radial fracture types, and has acceptable reliability comparable to commonly used systems. (10.1007/s11552-009-9163-1)
  • [L4] The goal of surgical fixation is a stable reduced joint that will tolerate immediate postoperative range of motion. (10.2106/jbjs.rvw.m.00049)
  • [Letter] The authors acknowledge that their biomechanical model represents an initial attempt to investigate the effect of forearm shortening on finger flexion and agree that an in vivo model incorporating active muscle contraction would be ideal. (10.1016/j.jhsa.2026.01.017)
  • [L4] The results provide new insight to the dynamics of hand movement as well as a basis for subsequent evaluations of movement patterns performed in ADLs and instrumental ADLs. (10.1007/s11552-013-9517-6)
  • [L4] Metallic hinged prostheses have been used to restore function in rheumatoid finger joints, with indications including gross joint destruction, dislocation, and persistent deformity. (10.2106/00004623-196143050-00011)
  • [L5] The paper recommends the adoption of the ObergeManskeeTonkin classification system to replace the Swanson classification, citing increased knowledge of molecular etiology and the need for a system that describes the limb axis and specific anomalies. (10.1016/j.jhsa.2014.12.001)
  • [L5] Ideally, digits need sensation and freedom of motion to enable patients to use them effectively, and effective surgery restores biomechanical motions so patients have optimum use. (10.1016/j.hcl.2013.08.003)
  • [L4] Management should be conservative, resisting surgical attempts to tighten the joint, and encouraging children to unlearn the habit. (10.1177/1753193416687915)
  • [L4] The proposed radiographic classification had prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures. (10.2106/00004623-198971090-00011)
  • [L4] Forearm positioning has great implications on daily functioning, as well as strength and skilled use of the hand. (10.1016/j.jht.2014.08.027)
  • [L4] It is unsuccessful when done in the face of poor indications, when the tendon is not freed completely, or when performed in association with complex orthopaedic procedures which do not permit early postoperative active motion. (10.2106/00004623-196749040-00009)
  • [L4] Nonoperative therapy is recommended as the initial treatment course. (10.1016/j.hcl.2008.03.002)
  • [L4] Fixation is possible up to 8 weeks after injury, though earlier treatment yields better range of motion outcomes. (10.1177/1753193413508514)
  • [L4] The authors propose an additional category (Type 3) to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual, which were not previously represented in existing classifications. (10.1016/j.jhsg.2023.10.005)
  • [L5] Additionally, surgical treatment targets treating joint imbalance to prevent fixed deformity. (10.1016/s0749-0712(03)00076-3)
  • [L5] Despite continued efforts to improve hand evaluation techniques, limitations in quantifying joint motion to exact precision persist even with in-person assessment. (10.1177/17531934231154158)
  • [L5] Using the proposed method, the thumb extension and abduction functions can be reconstructed without requiring a pulley. (10.1016/j.jhsg.2025.100781)
  • [L5] Mean forearm shortening of 3 or 4 cm resulted in near-complete loss of FDP simulated muscle force and tip-to-palm force in wrist-neutral and wrist-extension positions, respectively. (10.1016/j.jhsa.2024.09.005)
  • [L4] Currently, it is the most reliable tool for measuring thumb abduction. (10.1016/j.jht.2021.03.001)
  • [L5] Plain radiography provides the most basic and useful information, while MRI provides the most information about soft tissues. (10.1197/j.jht.2007.02.002)
  • [L5] Understanding foundational principles of anatomy and kinematics and initiating early mobilization are critical components in the treatment algorithm. (10.1177/17531934231185304)
  • [L4] There are different classification systems which were developed with various aims. (10.1016/j.jht.2023.05.008)
  • [L4] The authors propose a classification system to organize variations of the long extensor tendon to the thumb, aiming to help avoid confusion during surgeries involving repair or transfer of these tendons. (10.1007/s11552-010-9273-9)
  • [Commentary] The author argues that incongruous radiocarpal joints are well tolerated due to wrist biomechanics, particularly the role of the midcarpal joint in the dart-throwing motion, and questions the necessity of aggressive treatment for stepoffs larger than 1 mm. (10.1016/j.jhsa.2013.04.038)
  • [L4] Although there are limitations in the total degree of movement, the motion which persists is functional, pain relief has been substantial and the long term outcomes and follow-up suggest minimal deterioration. (10.1016/j.jhsa.2014.06.065)
  • [L5] The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis. (10.1007/s11552-013-9499-4)
  • [L4] No recurrence of radiocarpal translation was observed at long term follow-up. (10.1016/j.jhsg.2024.01.001)
  • [L4] Carpal fractures had a small negative effect on the Short Musculoskeletal Function Assessment Hand/Arm Index and EQ-5D scores 1 year after the injury. (10.1177/17531934231202012)
  • [L5] All imaging modalities (radiograph, CT, and MRI) demonstrated excellent inter-rater agreement with no significant difference in bias from the true variance when compared to each other. (10.1016/s0363-5023(11)60022-1)
  • [Paper] Soft tissue reconstructions alone are unlikely to correct deformity adequately or maintain correction long-term; joint procedures are preferred. (10.1016/j.hcl.2010.10.001)
  • [Case_report] Management principles remain the same with stabilisation of the entire bone and early mobilisation being appropriate. (10.1186/1749-799x-5-26)
  • [L4] No adverse events or revisions were reported. (10.1016/j.jhsa.2014.06.033)
  • [L3] No adverse events or revisions were reported. (10.1016/j.jhsa.2016.07.036)
  • [L5] The author notes that despite 70 years of research and numerous treatment options, the best management for trapeziometacarpal arthritis remains debated, with a constant proportion of patients remaining unhappy or symptomatic post-surgery. (10.1177/17531934221122987)
  • [L4] Conservative treatment is the initial approach, but surgical decompression is indicated if these measures fail. (10.2106/00004623-196951080-00016)
  • [L4] Nonoperative options are commonly used as first-line treatment for tenosynovitis of the hand and wrist, but questions remain regarding when to advance to operative intervention. (10.2106/jbjs.rvw.o.00061)
  • [L5] Management is dictated by classification, with initial conservative therapy followed by interventional options or surgery for persistent pain, swelling, or functional impairment. (10.5435/jaaos-22-06-352)
  • [L4] Radiological findings support good bone tolerance with signs of progressive integration, despite moderate erosion and bone remodeling in some cases. (10.1016/j.jhsg.2025.100804)
  • [L5] The overall health of the child and the severity of deformities guide long-term treatment plans aimed at realigning the forearm, wrist, and hand while providing a functional thumb. (10.5435/00124635-200701000-00005)
  • [L2] MRI alters the treatment of hand, wrist, and elbow conditions in less than 1 in 5 patients. (10.1177/1558944719861725)
  • [Letter] Thumb CMC joint arthritis is an expected part of aging, and many patients may become asymptomatic or minimally symptomatic; therefore, nonoperative care including therapy should be offered as first-line treatment as patients may find relief and never proceed with surgery. (10.1016/j.jht.2023.03.002)
  • [L4] Advanced imaging (bone scintigraphy and single-photon emission CT and standard CT) are helpful to confirm the diagnosis. (10.1016/j.jhsa.2021.02.017)
  • [L5] Vascularized bone graft is recommended when osteonecrosis of the proximal pole is evident on MRI. (10.5435/00124635-199407000-00001)
  • [Case_report] Conservative management resulted in a satisfactory short-term outcome for this elderly, low-demand patient with minimal symptoms. (10.1016/j.jhsg.2021.10.002)
  • [L4] This technique is advocated for complex recalcitrant non-unions where conventional grafts may fail due to poor vascularity. (10.2106/00004623-199072010-00015)
  • [Case_report] The early radiographic results of this reconstruction are promising. (10.1007/s11552-011-9361-5)
  • [L5] Standard radiographs provide between 53% and 90% sensitivity, while CT offers 94% specificity and 97% accuracy. (10.1016/j.jhsa.2013.06.004)
  • [Paper] MRI is not 100% specific for diagnosing an occult scaphoid fracture, with a specificity of 96% in healthy volunteers. (10.1016/s0363-5023(10)60085-8)
  • [L4] The patient remained pain- and symptom-free at 14 months with full range of motion and no recurrence on MRI. (10.1016/j.jhsg.2020.04.002)
  • [L5] The mandatory imaging work-up consists of radiographs and ultrasound, while MRI should be requested any time there are atypical findings such as bone extension of a soft tissue lesion, osteolysis, or size greater than 3 cm. (10.1016/j.otsr.2021.103153)
  • [L3] Patients requiring arthrodesis or amputation tended to be men in their sixties with comorbidities, an idiopathic cause, and delayed presentation. (10.1016/s0363-5023(10)60129-3)
  • [L4] The study describes the characteristics of the preserved anlage before and after surgical correction, noting that mild IP joint deformity may persist without functional impairment. (10.1177/1753193420948383)
  • [L4] The articular surface of the scaphoid remodels over time in skeletally mature subjects, with normal architecture completely restored by 3 years. (10.1007/s11552-010-9264-x)
  • [L4] Union was achieved in a relatively short period of time with a nonvascularised bone graft. (10.1177/1753193408090120)
  • [L4] The patient was free of pain with essentially normal range of motion at thirty-four months follow-up. (10.2106/00004623-198163060-00021)
  • [L4] Surgical removal of the cartilaginous ridge restored normal joint motion and the patient remained free of symptoms. (10.2106/00004623-196143020-00012)
  • [L4] While degenerative changes may occur, they did not necessarily result in disabling symptoms at the time of follow-up. (10.2106/00004623-197961060-00018)
  • [L5] Unrecognized joint incongruity in early-stage trapeziometacarpal arthritis is likely to lead to progression of joint degeneration, and recognition of this incongruity can lead to measures that may prevent or delay this progression. (10.1177/17531934221137780)

See Also

References

[1] Surgical management of osteoarthritis of the hand and wrist. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2022.01.001

[2] Joint Pain, Severe Cartilage Destruction, and Chondrolysis: Guidelines for Improving Diagnostic Differentiation and Clinical Management (SS‐22). Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.03.025

[3] Current Concepts in the Surgical Management of Rheumatoid and Osteoarthritic Hands and Wrists. Hand Clinics. 2011. DOI: 10.1016/j.hcl.2010.09.003

[4] Bone Lengthening in the Pediatric Upper Extremity. Journal of Bone and Joint Surgery. 2016. DOI: 10.2106/jbjs.16.00007

[5] The natural history of scaphoid non-union. A review of fifty-five cases.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567030-00013

[6] Carpal Coalitions on Radiographs: Prevalence and Association With Ordering Indication. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.02.002

[7] Radiographic Features of the Metacarpal in Blauth Type III Thumb Hypoplasia. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.04.005

[8] Inter- and Intrarater Reliability of Osteoarthritis Classification at the Trapeziometacarpal Joint. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.09.007

[9] Osteoid Osteoma of the Scaphoid Presenting with Radiocarpal Arthritis: A Case Report. HAND. 2009. DOI: 10.1007/s11552-008-9159-2

[10] Congenital Absence of Flexor Pollicis Longus Tendon without Associated Anomalies of Thumb Hypoplasia: A Case Report and Review of the Literature. HAND. 2007. DOI: 10.1007/s11552-007-9045-3

[11] RICHARDS, ROBIN R. M.D., F.R.C.S.(C)+, TORONTO, ONTARIO, CANADA. The Journal of Bone and Joint Surgery. American Volume. 1996.

[12] Arthritis of the Distal Radioulnar Joint: From Darrach to Total Joint Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/00124635-201210000-00002

[13] Arthroplasty in the hand: what works and what doesn’t?. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211017703

[14] Use of modified Viegas capsuloplasty for chronic scapholunate Geissler 3C lesions: long-term follow-up on 338 patients. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261454878

[15] The functional range of motion of the finger joints. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414533754

[16] Replacement of the Proximal Pole of the Scaphoid With a Pyrolytic Carbon Implant: A Case Study of Successful Rehabilitation. Journal of Hand Therapy. 2010. DOI: 10.1016/j.jht.2010.09.015

[17] Radiological imaging of the trapeziometacarpal joint: a historical and clinical perspective. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221137979

[18] Proximal Row Carpectomy Versus Scaphoid Excision and Intercarpal Arthrodesis: Intraoperative Assessment and Procedure Selection. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.032

[19] Reverse wedge osteotomy of the distal radius in Madelung's deformity. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.03.007

[20] THE ONE-BONE FOREARM: A Reconstructive Procedure.. The Journal of Bone and Joint Surgery. American Volume. 1955.

[21] Fracture-dislocation of the radiocarpal joint. The Journal of Bone & Joint Surgery. 1977. DOI: 10.2106/00004623-197759020-00011

[22] Fractures and dislocation of the base of the thumb metacarpal. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414554357

[23] Complications of scaphoid silicone arthroplasty.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567030-00012

[24] Twenty-Year Experience With Primary Distal Radioulnar Joint Arthroplasty From a Single Institution. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.02.014

[25] MatOrtho proximal interphalangeal joint arthroplasty: minimum 2-year follow-up. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415614251

[26] Metacarpophalangeal Hyperextension Deformity Associated With Trapezial-Metacarpal Arthritis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.006

[27] Carpometacarpal Fracture-Dislocations: A Retrospective Review of Injury Characteristics and Radiographic Outcomes. HAND. 2019. DOI: 10.1177/1558944719852743

[29] The natural history of scaphoid non-union.. The Journal of Bone & Joint Surgery. 1984. DOI: 10.2106/00004623-198466040-00003

[30] Preface. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2008.03.009

[31] Kinematic analysis of forearm rotation using four-dimensional computed tomography. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221142520

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

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

[34] Finger Metacarpophalangeal Joint Injuries in Athletes: Evaluation, Diagnosis, Treatment, and Return to Play. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-21-01031

[35] Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion) in Pediatric Phalanges. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.05.002

[36] Osteoid Osteoma in the Thumb of an Adolescent Patient. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.01.019

[37] Anatomy of the toe extensor tendons and its suitability for tendon grafts in the hand: a cadaveric study. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420936612

[38] Bilateral Scaphotrapezium Coalition with Bilateral Scaphoid Nonunion in a Patient with Klippel–Feil Syndrome: A Case Report. HAND. 2010. DOI: 10.1007/s11552-010-9304-6

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

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

[41] The Distal Radioulnar Joint:Problems and Solutions. Journal of the American Academy of Orthopaedic Surgeons. 1995. DOI: 10.5435/00124635-199503000-00005

[42] Quantified Contours of Curvature in Female Index, Middle, Ring, and Small Metacarpophalangeal Joints. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.10.004

[43] Tenosynovitis With Psammomatous Calcification Preoperatively Diagnosed as Intra-Articular Free Body of the Young Male Wrist: A Case Report. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2023.08.001

[44] Bone-Preserving Arthroscopic Options For Treatment of Thumb Basilar Joint Arthritis. Hand Clinics. 2011. DOI: 10.1016/j.hcl.2011.05.005

[45] The Effect of Surgical Treatments for Trapeziometacarpal Osteoarthritis on Wrist Biomechanics: A Cadaver Study. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.10.003

[46] Reliability of a Classification of Fractures of the Hand Based On the AO Comprehensive Classification System. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409355256

[47] Wrist Arthritis. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2005.08.013

[48] Synpolydactyly of the hand: a radiographic classification. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415598281

[49] Retrograde Drilling for the treatment of Capitellar Osteochondritis Dissecans (SS‐50). Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.03.054

[50] A novel hamatometacarpal fracture–dislocation classification system based on CT scan. Injury. 2012. DOI: 10.1016/j.injury.2012.02.019

[51] Biomechanical Measurement in Orthopaedic Practice. The Journal of Bone & Joint Surgery. 1987. DOI: 10.2106/00004623-198769070-00033

[52] The Effect of Lunate Morphology on the 3-Dimensional Kinematics of the Carpus. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.09.019

[54] Pathomechanics of the wrist following fractures of the distal radius. Hand Therapy. 2015. DOI: 10.1177/1758998315574352

[55] Efficacy of Surgical Interventions for Trapeziometacarpal (Thumb Base) Osteoarthritis: A Systematic Review. Journal of Hand Surgery Global Online. 2021. DOI: 10.1016/j.jhsg.2021.02.003

[56] Influence of the flexor digitorum superficialis tendon transfer on grip strength. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211061220

[57] The Buttazzoni Classification of Distal Radial Fractures in Adults: Interobserver and Intraobserver Reliability. HAND. 2009. DOI: 10.1007/s11552-009-9163-1

[58] Treatment of Monteggia and Transolecranon Fracture-Dislocations of the Elbow. JBJS Reviews. 2014. DOI: 10.2106/jbjs.rvw.m.00049

[59] Response to Letter to the Editor Regarding “The Effect of Forearm Shortening on Finger Flexion: A Biomechanical Study”. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.01.017

[60] Identification of Three Movement Phases of the Hand during Lateral and Pulp Pinches Using Video Motion Capture. HAND. 2013. DOI: 10.1007/s11552-013-9517-6

[61] Restoration of Rheumatoid Finger-Joint Function. The Journal of Bone & Joint Surgery. 1961. DOI: 10.2106/00004623-196143050-00011

[62] Classification of Congenital Anomalies of the Hand and Upper Limb. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.12.001

[63] Biomechanics of the Hand. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.08.003

[64] Habitual dislocation of the thumb metacarpophalangeal joint in children. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193416687915

[65] Fractures of the coronoid process of the ulna.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971090-00011

[66] Forearm Positioning and Its Functional Implications. Journal of Hand Therapy. 2016. DOI: 10.1016/j.jht.2014.08.027

[67] Tenolysis in the Hand and Wrist. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749040-00009

[68] Treatment of Scaphotrapezio-Trapezoid Arthritis. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2008.03.002

[69] Condylar fractures of the proximal and middle phalanges. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413508514

[70] Accessory Extensor Pollicis Longus Tendon Classification Modification. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2023.10.005

[71] Surgical management of wrist and finger deformity. Hand Clinics. 2003. DOI: 10.1016/s0749-0712(03)00076-3

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

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

[74] The Effect of Forearm Shortening on Finger Flexion: A Biomechanical Study. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.09.005

[75] Thumb carpometacarpal palmar and radial abduction in adults with thumb carpometacarpal joint pain: Inter-rater reliability and precision of the inter-metacarpal distance method. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2021.03.001

[77] Reprint of Diagnostic Imaging of the Shoulder. Journal of Hand Therapy. 2007. DOI: 10.1197/j.jht.2007.02.002

[79] Update on fractures of the carpus and hand. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231185304

[80] Do current upper limb orthotic classification systems help clinicians choose and design effective orthoses? A scoping review with expert interviews. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.05.008

[81] A Classification System for Anomalies of the Extensor Pollicis Longus. HAND. 2010. DOI: 10.1007/s11552-010-9273-9

[82] Commentary on “Articular Cartilage Thickness at the Distal Radius: A Cadaveric Study”. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.04.038

[83] Chapter 32 Pelvic Fractures: Definitive Treatment and Outcomes. 2021.

[84] Long-Term Outcomes of Scaphoid Hemi-Resection and Arthrodesis of the Radiocarpal Joint (the SHARC Procedure) for Isolated Radiocarpal Arthritis. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.065

[85] Scapholunate Ligament Injuries: A Review of Current Concepts. HAND. 2013. DOI: 10.1007/s11552-013-9499-4

[86] Successful Diagnosis and Treatment of Traumatic Radiocarpal Translocation. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.01.001

[87] Carpal fractures: epidemiology, classification and treatment of 6542 fractures from the Swedish Fracture Registry. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231202012

[88] Ulnar Variance: Correlation of Radiographs, CT, and MRI with Anatomic Dissection. The Journal of Hand Surgery. 2011. DOI: 10.1016/s0363-5023(11)60022-1

[89] Rheumatoid Thumb. Hand Clinics. 2011. DOI: 10.1016/j.hcl.2010.10.001

[90] Hypertrophic non-union of a pathological forearm fracture secondary to multiple myeloma: a case report. Journal of Orthopaedic Surgery and Research. 2010. DOI: 10.1186/1749-799x-5-26

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

[92] Can Processed Nerve Allografts be Used to Repair Nerve Injuries Greater than 4cm for the Return of Critical Function in the Upper Extremity?. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.036

[93] Trapeziometacarpal arthritis: 70 years after Gervis. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221122987

[94] The Extensor Indicis Proprius Syndrome. The Journal of Bone & Joint Surgery. 1969. DOI: 10.2106/00004623-196951080-00016

[95] Tenosynovitis of the Hand and Wrist. JBJS Reviews. 2016. DOI: 10.2106/jbjs.rvw.o.00061

[96] Vascular Anomalies of the Hand and Wrist. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-06-352

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

[98] Radial Longitudinal Deficiency. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200701000-00005

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

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

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

[102] Scaphoid Nonunion. Journal of the American Academy of Orthopaedic Surgeons. 1994. DOI: 10.5435/00124635-199407000-00001

[103] Posttraumatic Ulnar Translocation of the Carpus: A Case Report and Brief Review of the Literature. Journal of Hand Surgery Global Online. 2022. DOI: 10.1016/j.jhsg.2021.10.002

[104] Recalcitrant non-union of the scaphoid treated with a vascularized bone graft based on the ulnar artery.. The Journal of Bone & Joint Surgery. 1990. DOI: 10.2106/00004623-199072010-00015

[105] Triquetral Autograft for Restoration of the Lunate Fossa of the Distal Radius: A Case Report. HAND. 2011. DOI: 10.1007/s11552-011-9361-5

[106] Hook of Hamate Fractures. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.06.004

[108] False Positive MRI's for Scaphoid Fracture in Healthy Volunteers. The Journal of Hand Surgery. 2010. DOI: 10.1016/s0363-5023(10)60085-8

[109] A Juxta-Articular Myxoma of the Thumb. Journal of Hand Surgery Global Online. 2020. DOI: 10.1016/j.jhsg.2020.04.002

[110] Diagnosis and treatment of hand tumors. Orthopaedics & Traumatology: Surgery & Research. 2022. DOI: 10.1016/j.otsr.2021.103153

[113] Outcomes of Septic Arthritis of Small Joints of the Hand. The Journal of Hand Surgery. 2010. DOI: 10.1016/s0363-5023(10)60129-3

[115] Floating thumb duplication: characteristics of the preserved anlage before and after surgical correction. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420948383

[116] A Qualitative Evaluation of Scaphoid Remodeling in Bone-Grafted Scaphoid Nonunions. HAND. 2010. DOI: 10.1007/s11552-010-9264-x

[117] Congenital Bilateral Pseudarthrosis of the Index Metacarpal Bones. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408090120

[118] Dislocation of the triangular bone. Report of a case.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163060-00021

[119] A Locking Little Finger. The Journal of Bone & Joint Surgery. 1961. DOI: 10.2106/00004623-196143020-00012

[120] Multiple carpometacarpal dislocations. A review of four cases.. The Journal of Bone & Joint Surgery. 1979. DOI: 10.2106/00004623-197961060-00018

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

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Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.