Wrist Deformity Research Articles

Radial Longitudinal Deficiency: Description of a Novel Surgical Technique and Clinical Cases

Radial longitudinal deficiency III and IV present as a short upper limb, functional elbow, and wrist with severe radial and palmar angulation, where the carpus articulates with the radial and palmar edge of the ulna, allowing limited mobility in a nonfunctional position. Surgical treatment aims to correct radial angulation and flexed carpal position, often altering carpal positioning over the distal ulna and impacting wrist mobility. In addition, fixation through distal ulnar epiphysis affects its growth. Although these procedures improve appearance, functionality remains suboptimal. This study describes a novel ulnar osteotomy and extensor carpi ulnaris transfer for the correction of wrist deformity in radial longitudinal deficiency with preservation of ulnocarpal motion and epiphyseal growth. The surgical technique, indications, contraindications, and potential complications are described. Three cases with postoperative follow-ups at 36, 12, and 6 months, evaluating deformity and pre/postsurgical wrist mobility ranges, are reported. A correction was achieved in the forearm-hand angle of 71 to 88 degrees of the initial. The total range of movement, between 50 degrees and 80 degrees, was almost the same before and after the operation in the most anatomic position. In one patient, there was a residual deformity at the dorsoradial border, which showed no progression during the last 6 months of follow-up. For patients with radial longitudinal deficiency, functional outcomes with preserved mobility appear to hold greater significance. The technique described in this study enabled deformity correction while maintaining a wide range of motion. The preservation of the physis in a different orientation is an aspect that will need evaluation in long-term follow-up but offers potential treatment options in the future; due to the unknown of the secondary deformity, it is recommended that the long-term results should be awaited before adoption of this technique.

Scaphocapitate Arthrodesis for Wrist Deformities: A Systematic Review.

Scaphocapitate arthrodesis (SCA) is a described technique for chronic wrist pathology such as Kienbock disease and carpal instability. The technique aims to preserve motion, while maintaining carpal height, preserving the radioscaphoid articulation, and offloading the lunate. Limited case series evaluate the outcomes of this previously described technique. We aim to determine if the collective, updated literature on outcomes of SCA support its continued application by the wrist surgeon. Furthermore, we investigated if any technical variations offer an advantage in improving patient-reported outcomes after SCA. A literature search was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles selected for critical review were examined for patient demographic data, functional outcomes, radiographic outcomes, and complications. A qualitative analysis was then performed to synthesize the available date. A total of 18 unique articles published between 1991 and 2022 were identified, representing a total of 285 individual cases of SCA. Nonunion rate ranged 0%-22%. Preoperative visual analog scale pain scores ranged from 3.2 to 10, whereas postoperative visual analog scale pain scores ranged from 0 to 4. Patient-reported outcomes are reported by validated instruments, including the Disabilities of the Arm, Shoulder, and Hand, QuickDASH, Patient-rated Wrist Evaluation, and Mayo Wrist Score. SCA is a viable treatment option for patients with Kienbock disease. SCA offers reliable improvements in patient pain, grip strength, and patient-reported outcomes.

Contemporary view on the care of the rheumatoid wrist.

Rheumatoid arthritis (RA) is a common inflammatory condition that can lead to debilitating hand and wrist deformity. Since the introduction of disease-modifying antirheumatic drugs in the 1990s, the rate of surgery for rheumatoid arthritis has dramatically decreased 1. Nonetheless, surgical intervention remains an important tool in the management of patients with RA, and young surgeons must seek out expertise in this domain due to diminished exposure during their training. In this article, we provide a comprehensive review of the evaluation and management of patients with wrist pathology due to RA as well as surgical technical pearls.

Single-Portal Arthroscopy Improves the Assessment of Radial-sided Disorders of the Wrist

Abstract Purpose This study aimed to describe the technique, indications, and advantages of the single-portal arthroscopic approach for the diagnosis and staging of chronic radial-sided disorders, including scapholunate interosseous ligament (SLIL) tear, scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) deformities. Methods The single portal technique was used in 138 patients affected by suspected SLIL lesions, SLAC and SNAC wrist injuries with positive clinical symptoms and inconclusive imaging (X-ray and MRI). It was used to grade the nature of the SLIL lesion and the extension of the osteochondral damage in the SLAC and SNAC wrist deformity to guide appropriate treatment. Results Patients were divided into group 1 (SLIL: 45 cases), group 2a (SLAC: 65 cases), and group 2b (SNAC: 28 cases). In group 1, stage 4 SLIL lesions were confirmed in 36 cases and 9 were assessed as SLAC wrist deformity. In group 2a, single-portal arthroscopy confirmed the preoperative diagnosis in 74% of cases. In the remaining 26% of patients, arthroscopy modified the preoperative diagnosis: 1 case of SLAC 1 resulted in SLAC 2, 14 cases of SLAC 2 resulted in SLAC 3, 1 case of SLAC 3 resulted in SLAC 2. A case of SLAC 2 turned out to be an SLIL lesion stage 4. In group 2b, single-portal arthroscopy confirmed the preoperative diagnosis in 86% of cases. In the remaining 14% (4 cases), it modified the preoperative diagnosis: 1 of SNAC 1 resulted in SNAC 2 and the other in SNAC 3, 1 case of SNAC 2 turned out to be an SNAC 3, and 1 case of SNAC 3 resulted in SNAC 4. Conclusion Single-portal wrist arthroscopy modified the preoperative diagnosis of wrist pathology in 42 patients over 138 cases. The use of single-portal wrist arthroscopy should be considered in the evaluation of the radiocarpal and midcarpal joints to allow accurate visualization of the joint surfaces for surgeon and patient planning. Type of Study/Level of Evidence Observational study level of evidence IV.

Combined Wrist Extensor Tenodesis and Tendon Transfers for Severe Spastic Flexed Wrist Deformity: Surgical Technique and Case Series.

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient's characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.

Snapping Wrist From Bowstringing of the Digital Flexors After Carpal Tunnel Release: A Case Report.

Symptomatic bowstringing of digital flexor tendons is a rare complication of carpal tunnel release (CTR). Two weeks after open CTR, a 47-year-old man with severe carpal tunnel syndrome had relief of his preoperative median paresthesia but complained of new-onset painful snapping of the wrist and transient ulnar paresthesia occurring with wrist dorsiflexion and concomitant digital flexion. Physical examination localized the audible snapping to the hook of hamate (HOH) where manual pressure eliminated the wrist motion-induced snapping and the associated ulnar paresthesia. Wrist radiographs showed stage III scapholunate advanced collapse (SLAC) with marked palmar subluxation of the lunate. Wrist magnetic resonance imaging revealed palmar and ulnar subluxation of the digital flexors over the HOH due to the mass effect of the palmarly displaced lunate and the chronic carpal malalignment. The snapping wrist and accompanying ulnar paresthesia resolved after HOH excision, and no additional treatment for the asymptomatic SLAC wrist deformity was required. Satisfactory clinical outcome was observed at 5-year follow-up.

Charcot’s Arthropathy of the Wrist: A Case Report

Introduction: Charcot arthropathy is a myriad of osseous degenerative changes that can affect theoretically any joint of the body. The pathophysiology of this condition is based on microtrauma, leading to the deterioration of articular nerves. The most common cause in the upper extremity is syringomyelia. Case Report: A 64-year-old male patient presented with painless right wrist swelling and deformity. His radiographs showed degenerative changes in radiocarpal and intercarpal joints. Magnetic resonance imaging of the brain and cervical spine demonstrated Type II Chiari malformation and syringomyelia, and neurological evaluation revealed myelopathy. Conclusion: Charcot arthropathy of the wrist, an exceedingly rare condition, is a diagnosis of exclusion. The common causes of arthritis of the wrist such as Rheumatoid arthritis and tuberculosis must be ruled out. When a patient presents with wrist Charcot arthropathy thorough neurological examination must be done. Diabetes mellitus, tabes dorsalis, and leprosy are the other frequently cited causes that must be looked for. Keywords: Charcot arthropathy, wrist, syringomyelia.

Impact of rheumatoid arthrtis on functional limitations of wrist and hand

Background: Rheumatoid arthritis is associated with various wrist and hand deformities and malalignment, this makes activities of daily living difficult to perform. Identification of these functional limitations in early stages is imperative as it can change the course of the disease and prevent further deterioration of the joints. Results: On an average 38.5% subjects reported affection in their overall hand functions, 50.7% subjects reported difficulty in performing activity of daily living, 82.5% subjects reported disturbance in their work performance. Conclusion: The study of functional limitations of wrist and hand in rheumatoid arthritis is an important step forward to understand the disease in different stages and its impact on wrist and hand functional limitations to effectively start early physiotherapy rehabilitation to prevent the progression of disease as well as treat signs and symptoms too.

One-Bone Forearm Procedure for Severe Recalcitrant Forearm Deformities in Masada IIb Hereditary Multiple Exostoses.

Hereditary multiple exostoses (HME) Masada IIB has traditionally been treated by gradual ulnar lengthening with questionable efficacy in reducing the dislocated head. One-bone forearm (OBF) has been used as a reconstructive procedure in forearm deformities with very scarce literature for HME. The study aims to report short-term results of OBF as a definitive procedure for severe forearm deformities in Masada IIB patients with respect to clinical and radiological parameters. Four patients with HME Masada IIb were included in this retrospective study. All patients complained of forearm and wrist deformity with an abnormal bony protrusion restricting elbow motion. Indications for OBF were ulnar shortening > 3cm, dysplastic proximal radius with convex radial head and restricted prono-supination. All patients were examined pre-operatively and post-operatively clinically and radiographically using the Peterson's outcome score. The average age was 13 years (12-14years). Pre-operative ulnar shortening, carpal slip percentage, and radial articular angle was 3.4 cm, 79.5%, and 47.5°, respectively. All radial heads were dislocated with convex articular surface restricting elbow extension and forearm prono-supination. At the latest follow-up, the mean elbow flexion was 110° with forearm in 10° supination. The mean carpal slip percentage, radial articular angle, and Peterson functional grade was 15%, 22.5°, and 8 points, respectively. The mean follow-up period was 30.25 months with no recurrence. We recommend one bone forearm as a definitive procedure in HME Masada IIB patients with severe forearm deformities with ulnar shortening > 3cm and dysplastic proximal radius with a dislocated radial head, for faster return to function.

Analysis of the effectiveness of sequential plate internal fixation in correction of Madelung deformity after ulnar osteotomy and shortening

To investigate the effectiveness of sequential plate internal fixation in the correction of Madelung deformity after ulnar osteotomy and shortening. The clinical data of 13 patients with Madelung deformity admitted between September 2015 and July 2021 were retrospectively analyzed. There were 5 males and 8 females with an average age of 18.3 years ranging from 17 to 23 years. The disease duration ranged from 12 to 24 months, with an average of 17 months. Three cases had a clear history of trauma. All patients had external radial deviation deformity and limited movement of the ulnar deviation, and the ulnar impact pain was significant during ulnar deviation movement; 9 patients had limited wrist joint supination movement, and the supination movement was normal. In the first stage, ulnar osteotomy and shortening combined with external fixator were used to correct wrist deformity in 13 patients. After operation, bone transfer was performed 6 times per day, with adjustments made every 4 hours, which was 1 mm per day. After the osteotomy was in place, the ulnar plate internal fixation was performed to reconstruct the ulnar stability in the second stage. The Cooney wrist joint score was used to assess the pain, function, range of motion, flexion and extension range of motion, and grip strength of the wrist joint before operation and before the removal of internal fixator. The subjective feeling and appearance satisfaction of patients were recorded. After the second-stage operation, all the 13 patients were followed up 10-22 months, with an average of 15 months. The deformity of wrist joint disappeared after operation, and the flexion, extension, and ulnar deviation were basically normal. There was no complication such as ulnar impingement sign, nonunion or infection. Wrist function, pain, and range of motion were significantly improved after operation, except for 1 patient who had no significant improvement in rotation and pain. The ulnar internal fixator was removed at 10-18 months after the second-stage operation. The scores of pain, function, range of motion, flexion and extension range of motion, and grip strength in the Cooney wrist score before removal of internal fixator significantly improved when compared with those before operation ( P<0.05). Subjective and appearance satisfaction of patients were excellent in 9 cases, good in 3 cases, and fair in 1 case. Ulnar osteotomy and shortening with sequential plate internal fixation for correction of Madelung deformity, with mild postoperative pain, can effectively avoid bone nonunion, improve wrist joint function, and have significant effectiveness.

Use of volar distal radius plate dorsally for wrist arthrodesis in patients with upper limb spasticity: A retrospective review

Standard wrist arthrodesis implants are generally designed for adult joints with arthritis. They are often too big for patients with limb spasticity who generally tend to have osteopenic and smaller bones for their age, resulting in high complication rates. We previously described the novel use of volar distal radius variable-angle locking plate (APTUS® Wrist distal radius system 2.5, Medartis AG, Basel, Switzerland) on the dorsum for wrist arthrodesis in patients with limb spasticity. This study aimed to further establish the use of the implant by reporting the outcomes in cohort A (nondistal radius plate) and cohort B (distal radius plate cohort). Patient-reported outcome measures were used to assess the primary outcome, whereas secondary outcomes included implant-related complications and improvement in wrist position and fusion rates. A total of 17 wrist arthrodesis procedures were performed over a period of 4 years in 15 patients for wrist deformity secondary to limb spasticity. There were no complaints of implant prominence, implant or tendon irritation, metacarpal prominence, or extension requiring further treatment in cohort B. Cohort A had a high implant removal rate that is comparable to the published literature. Both groups reported significant improvement in hygiene and wrist position but neither group had any appreciable gain in function. Volar distal radius variable-angle locking plates appear to be safe and have superior patient acceptability and low complication rates when used dorsally for wrist arthrodesis in patients with upper limb spasticity. Comparable overall satisfaction rates in cohort B were reported in relation to the literature and the cohort A in this study.

A new incision in the correction of radial longitudinal deficiency: The double Y sliding flap approach

One concern in the surgical treatment of radial longitudinal deficiency (RLD) is certainly the skin incision. Over the years many different types have been proposed and used. We propose a new skin incision technique: a double Y sliding flap with the main body along the dorsal wrist crease, followed by raising a proximal and a distal flap providing wide access to the dorsal surface of the wrist joint. After correction of the wrist deformity, skin triangles are resected on the radial and ulnar sides of the incision. Then the skin of the distal flap is slid radially and proximally, filling the defect left by the resected radial triangle, while the proximal flap is slid in the opposite direction, enabling transverse closure along the ulnar side of the incision. The final scar comprises a central body along the dorsal wrist crease, and a radial branch. The aim of this study was to analyze the clinical results of this new double Y sliding flap approach for the surgical treatment of type III and IV RLD. We retrospectively reviewed medical records of surgical correction of RLD using our new incision, between January 2016 and December 2018 in our department of hand surgery. Endpoints comprised correction of redundant skin, scar appearance, and complications. Twelve limbs in 9 patients treated with this double Y sliding flap approach were reviewed: correction of redundant skin was systematic, only 2 limbs showed postoperative complications (1 case of notable edema and 1 of delayed wound healing), and scar aspect was graded good in 11 of the 12 cases. The double Y sliding flap was safe, with minimal complications, adequate skin restoration, wide exposure of the wrist, and esthetically good scar. Level of evidenceIV

PERILUNATE INSTABILITY AND DISLOCATION: A COMMONLY MISSED DIAGNOSIS

Perilunate dislocations and perilunate fracture-dislocations are high-energy wrist injuries, characterized by a spectrum of bony and ligamentous damage. Clinical presentation often includes decreased range of motion, swelling and pain, and a palpable wrist deformity, while radiographic evaluation of the wrist may reveal abnormal radiocarpal and intercarpal collinearity and bony insult. This particular trauma may be difficult to detect due to nonspecific clinic presentation and subtle imaging findings, and can be missed in up to 25% of initial evaluations. Prompt recognition is essential for optimal patient outcomes, as the majority of patients are young adults and thus duration of disability is significant.

OR18-6 Tracking the Diagnosis and Progression of Madelung Deformity in Pediatric Turner Syndrome Patients

Abstract Background Turner syndrome (TS) is a chromosomal anomaly occurring in females which presents with numerous medical and developmental manifestations including skeletal deformities. A specific developmental skeletal dyplasia seen in TS patients is Madelung deformity (MD), characterized by a growth deficiency of the distal radial physis that causes excessive radial inclination and volar tilt, with resultant ulnocarpal impaction. Surgical intervention, particularly in early stages, can halt progression of or reverse MD. Despite a considerable body of literature highlighting the presence of MD in TS, it is often underdiagnosed, in part due to a lack of data documenting the epidemiology and natural history. Objective Analyze the frequency of diagnosis of MD in patients meeting key radiographic threshold criteria and document the time course of the deformity in these patients using these parameters. Methods From a database of 264 patients with a confirmed diagnosis of TS, bone age radiographs for 187 (71%) were retrospectively measured against generally accepted cutoffs for MD using two parameters: ulnar tilt = UT and lunate subsidence = LS. For patients meeting general inclusion criteria of UT &amp;gt; 33° or LS &amp;lt; 0 mm, historical measurements of UT and LS were obtained using past bone ages and patients’ charts were reviewed to determine if a clinical diagnosis of MD was made. Results 7 patients (7/187 = 3.7%) met overall inclusion criteria and had radiographs consistent with Madelung Deformity. Of these 7, only one clinical diagnosis (14%) of MD was made; this patient underwent subsequent surgical intervention. The 6 undiagnosed patients had an average UT and LS of 40.5 degrees and -4.4 mm at the time of most recent bone age (∼16.3 years old). The time-courses for 4 (UT) and 3 (LS) of the 6 non-surgical patients were plotted over time from 7.2–18.9 years of age. Patients crossed threshold at an average age of 15.3 and 13.6 years for UT and LS, respectively. Average maximum read-to-read growth rates of 5.3 degrees and 3.5 mm occurred at an average age of 15.3 (UT) and 14.2 years (LS). Conclusion Our results suggest MD is significantly underdiagnosed in patients with TS, highlighting the need for better screening tools to make this diagnosis. This would include physical examination looking for the characteristic wrist deformity and careful analysis of bone age radiographs at an earlier age, when corrective surgery is more likely to succeed. We recommend careful scrutiny of yearly bone age radiographs from 10-15 years of age to ensure that the diagnosis of MD is not missed, and obtaining bilateral wrist radiographs (PA and Lateral views) for verification. Future research should focus on documenting disease progression using radiographic trends, as well as assessing how onset and progression are affected by therapeutic interventions such as growth hormone. Presentation: Monday, June 13, 2022 12:15 p.m. - 12:30 p.m.

The radiographic quality of conservatively managed distal radius fractures in adults using haematoma block versus intravenous sedation.

We compared the radiographic quality of initial reduction of distal radius fractures reduced using haematoma block to those reduced with intravenous sedation. The overall rate of re-manipulation and complications were noted. A prospective study carried out at the emergency unit of our hospital between 1st September, 2017 and 31st December, 2018. Patients were consecutively recruited into Haematoma Block (HB) and Sedation(S) groups using the simple balloting method. After 5-10min of administering anaesthesia, the fracture was reduced and immobilized in a below-to-elbow Plaster of Paris (P.O.P) cast for 6weeks. The pre- and post-reduction radiographs were reviewed for volar tilt, radial angulation, radial deviation and radial shortening. Sixty-seven patients completed the study with 33 patients in HB group and 34 patients in S group. There was no significant difference in the radiographic quality of initial reduction between the two groups using the Sarmiento's modification of Lindström criteria (p = 0.49). Five out of 34 patients among the sedated group had gastrointestinal symptoms. The overall rate of re-manipulation was low and the complications recorded were wrist stiffness and residual wrist deformity. Our study revealed that there was no significant difference in the radiographic quality of initial reduction between the groups. Excellent to good reduction was achieved with both anaesthetic options. The choice of anaesthesia should be individualized and based on surgeons' preference.

The outcome of Sauve Kapandji procedure on patient with DRUJ arthritis: A case report

BackgroundThe distal radioulnar joint (DRUJ) is frequently involved in inflammatory diseases, both de-generative and notably traumatic, resulting in pain, wrist motion and strength loss, and severe functional impairment. DRUJ dysfunction can be highly incapacitating. The Sauve-Kapandji (SK) procedure can be indicated to address multiple etiologies of DRUJ dysfunction.Case presentationA 54-year-old woman presented with pain and difficulty moving the left wrist. X-ray imaging revealed the union of the distal radius with the plate still in there with subluxation of the distal radioulnar joint after surgery in 2005. Afterwards, she underwent the Sauve-Kapandji procedure. Follow-ups were done at periodic intervals, and wrist physiotherapy was instituted. We evaluated the range of motion and the VAS score as well. The patient had acceptable motion after four weeks of evaluation.DiscussionThe SK method has been advocated as a treatment for DRUJ derangement because, un-like the Darrach surgery, it preserves the ulnar head at the wrist. As with the Darrach opera-tion, postoperative instability of the proximal ulnar stump or radioulnar convergence may occur despite the favourable clinical prognosis.ConclusionThe Sauve-Kapandji procedure could treat wrist pain and deformity in DRUJ arthritis. It gives a good result in two weeks, four weeks, twelve weeks, and twenty after the procedure. The peak time of recovery is four weeks after the procedure.

Distraction osteogenesis at the proximal third of the ulna for the treatment of Masada type I/IIb deformities in children with hereditary multiple exostoses: a retrospective review of twenty cases.

Ulna distraction by monolateral external fixator (MEFix) is a good option for the treatment of Masada type I and IIb deformities in children with hereditary multiple exostoses (HMEs). However, there is no consensus regarding where to perform ulnar osteotomy. Our hypothesis is that osteotomy at the proximal third of the ulna and progressive distraction with MEFix can simultaneously correct elbow and wrist deformities in patients with HME. We retrospectively reviewed patients with HME who underwent ulna distraction osteogenesis from June 2014 to March 2019. The carrying angle (CA), radial articular angle (RAA), ulnar variance (UV), radial variance (RV) and range of motion (ROM) of the affected forearm and elbow were clinically assessed before lengthening and at the last follow-up visit. The total ulna lengthening distance (LD) and radiographic outcome were also recorded. Nineteen patients (20 forearms) with HME aged 9.1 ± 2.4years at the time of surgery were retrospectively reviewed. The mean follow-up period was 26.1 ± 5.6months. There were 11 patients (12 forearms) with Masada type I deformities and eight patients (8 forearms) with Masada type IIb deformities. Patients with type IIb deformity had higher RV, lower CA values, less elbow flexion and forearm pronosupination than those with type I deformity (p < 0.05); RV was an independent risk factor for radial head dislocation, with the cut off at RV > 15.5mm. The mean LDs in patients with type I and type IIb deformities were 33.6 ± 6.6mm and 41.4 ± 5.4mm, respectively. The mean CA, UV, RV, forearm pronation and ulna deviation at the wrist improved significantly following surgery in all patients. In particular, five of eight patients (62.5%) with type IIb deformities had concentric reduction of the radiocapitellar joint, while no radial head subluxation was detected in patients with type I deformities at the last follow-up. Three complications were recorded: two pin-track infections and one delayed union. Distraction osteogenesis at the proximal third of the ulna provides satisfactory clinical and radiological outcomes in patients with Masada type I and IIb deformities. Early treatment of Masada type I deformities is indicated before progression to more complex type IIb deformities.

Modified Boyes' procedure for the multiple finger extensor tendon ruptures in patients with rheumatoid arthritis: A report of two cases.

Multiple subcutaneous extensor tendon ruptures in more than the ulnar three fingers sometimes occur in patients with rheumatoid arthritis accompanied by wrist deformity. In these situations, the flexor digitorum superficialis tendon of the middle finger (the FDS3 tendon) and that of the ring finger (the FDS4 tendon) are used for the transferred tendon (modified Boyes' procedure). Here, we treated two patients with rheumatoid arthritis, whose extensor tendons of more than three fingers were ruptured, using the modified Boyes' procedure. Case 1 had ruptures in four fingers (index through little), and Case 2 had ruptures in three fingers (middle through little). The FDS3 and FDS4 tendons were passed subcutaneously around the radial side of the wrist to the extensor sides and interlaced with the distal stump of the ruptured tendons. Switching of the finger movement was achieved smoothly in both cases. The post-operative evaluation showed an extension lag of -15° for the index finger 0° for the middle through the little fingers in Case 1, and 0° for the middle finger and -5° for the ring and little fingers in Case 2. The average post-operative extension lag was -3.5°. However, median nerve palsy occurred in both cases, and it gradually recovered. Stretching of the nerve by the correction of the wrist deformity and increased pressure in the carpal tunnel were supposed to be causes of this palsy. Modified Boyes' procedure is a useful method for more than three ulnar finger extensor tendon ruptures; however, post-operative median nerve palsy should be considered.

Comparison of outcome between operative treatment and constraint-induced movement therapy for forearm and wrist deformities in cerebral palsy. A randomized controlled trial

Several treatment strategies for upper extremity deformities in cerebral palsy have been studied for their effectiveness in terms of function and quality of life. There are a few comparative studies between nonoperative and operative management for upper extremity deformities. This study aimed to compare the outcomes between conservative methods using constraint-induced movement therapy (CIMT) and operative methods using pronator teres rerouting, flexor carpi ulnaris transfer to extensor carpi radialis brevis (FCU transfer to ECRB) and fractional lengthening in cerebral palsy patients with forearm pronation and wrist flexion contracture. A total of 19 participants aged 7-15 years were randomized to either CIMT or surgery. The primary endpoint was changes in Shriners Hospital Upper Extremity Evaluation (SHUEE) functional score. Secondary endpoints comprised range of motion, Volkmann’s angle, and the Pediatric Outcomes Data Collection Instrument (PODCI). At 1-year follow-up, there was no significant difference between the nonoperative and operative groups in any SHUEE dimensions, range of motion or PODCI. However, there was significant improvement in Volkmann’s angle in the operative group compared to the CIMT group: CIMT = 11.11 ± 9.92, surgery = -13.00 ± 4.72: p = 0.04 (95% CI = 1.68-46.54). Operative treatment provided more improvement in wrist posture, represented by Volkmann’s angle, in cerebral palsy patients. However, SHUEE, range of motions and PODCI were comparable between the CIMT and operative groups.

Assessment of Current Trends in Demographic and Clinical Characteristics of Male Patients with Rheumatoid Arthritis: A Retrospective Study

Introduction: Role of gender in development of an autoimmune dysfunction in Rheumatoid Arthritis (RA) is very complex and therefore novel concept of gender medicine has come into limelight. Aim: To assess current trends in demographic and clinical characteristics of male patients with RA. Materials and Methods: This retrospective study was conducted among patients with RA attending Outpatient Department of Rheumatology at Santokba Durlabhji Memorial Hospital cum medical Research Institute, Jaipur and Centre for Arthritis and Autoimmune Rheumatic Disorders, Jaipur, Rajasthan, India, during April 2015 to April 2021. Men who qualified the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) criteria for RA were included in this study. The medical records of patients were reviewed for collecting demographic and clinical characteristics, disease activity, disease duration, deformities, extra articular manifestations, and co-morbid illness. Results: A total of 179 men were enrolled, and the mean age was 45.3±11.1 years. The majority of patients had severe disease with more than two years of disease duration. Subcutaneous nodule (27.8%) was most frequently observed extra-articular manifestations. Rheumatoid factor positivity and cyclic citrullinated peptide were prevalent in 107 and 110 patients, respectively. Osteoporosis (21.1%) and hypertension (19.2%) were the most common comorbidities and majority of patients reported wrist deformities. Conclusion: Overall observations indicate the presence of subcutaneous nodule as the common extra-articular manifestation with more than 2 years of disease duration, osteoporosis and hypertension as the most common co-morbidities; and high prevalence of wrist deformities in male patients with RA.