LETTERS TO THE EDITOR
Ultrasonography Can Be Used to Assess Phalanx Fractures To the Editor: A 27-year-old man presented with trauma to the ring finger of the left hand, which had occurred one week previously. Pain had suddenly started after he experienced a crush injury during a football game. On physical examination, palpation of the fourth distal phalanx was painful. He could not voluntarily extend the distal phalanx of the fourth digit and he had local swelling. Radiologic evaluation showed a displaced intra-articular fracture of the fourth distal phalanx (Fig. 1A). Ultrasonography (US) was selected as an additional method of assessment and the US image confirmed an avulsed fragment from the distal interphalangeal joint (Fig. 1B, C). The patient was
referred to the hand surgery unit, where he was treated with open reduction internal fixation using Kirschner wires. Phalangeal fractures present as common sports and workplace injuries; they comprise half of all hand fractures. Sports-related injuries are particularly common in the third decade of life, and workrelated injuries in the fifth decade. These fractures are commonly caused by trauma or crush injuries.1 Radiography is routinely performed to evaluate bone injuries. It should be undertaken initially in at least 2 planes centered at the level of the suspected injury, but the possibility of using a noninvasive technique without exposure to ionizing radiation to
FIGURE 1: A X-ray showing the fracture line at the fourth phalanx (arrow). B Longitudinal ultrasonographic view. Insertion of extensor digitorum tendon (thin white arrows) to the avulsed part (outlined arrow) of the distal phalanx. C The axial view designates the fracture line at the fourth distal phalanx (white arrows). D The healthy side. DP, distal phalanx; MP, middle phalanx.
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1057
1058
LETTERS TO THE EDITOR
diagnose a fracture has raised interest in the use of US. Ultrasound performed by an experienced person may be useful in assessing ligament and tendon integrity, evaluating bone cortex integrity, and detecting radiolucent foreign bodies.2 Because plain radiographs provide one-dimensional images, phalanx fractures may sometimes be missed. In addition, in our case study, US revealed a small avulsed bony fragment in close relation to the dorsal lip of the distal phalanx. For this reason, 2-dimensional US images may provide greater accuracy in fracture diagnostics. Ultrasound can be beneficial in diagnosing occult fractures, especially in children,3 when plain radiographs may have been evaluated as normal. This method can also be used as a guide to select surgical methods used to treat fractures. Ultrasound has gained increasing importance in the field of sports medicine and rehabilitation practitioners in identifying structural changes within tissues and joints.4 It should be considered the first-line imaging method
in assessing not only soft tissue injuries but also fractures. Mustafa Turgut Yildizgoren, MD Musa Demirkapi, MD Ayse Dicle Turhanoglu, MD Department of Physical Medicine and Rehabilitation Mustafa Kemal University Medical School Hatay, Turkey http://dx.doi.org/10.1016/j.jhsa.2015.02.022 REFERENCES 1. Bendre AA, Hartigan BJ, Kalainov DM. Mallet finger. J Am Acad Orthop Surg. 2005;13(5):336e344. 2. Williamson D, Watura R, Cobby M. Ultrasound imaging of forearm fractures in children: a viable alternative? J Accid Emerg Med. 2000;17(1):22e24. 3. Neri E, Barbi E, Rabach I, et al. Diagnostic accuracy of ultrasonography for hand bony fractures in paediatric patients. Arch Dis Child. 2014;99(12):1087e1090. 4. Tok F, Özçakar L, De Muynck M, Kara M, Vanderstraeten G. Musculoskeletal ultrasound for sports injuries. Eur J Phys Rehabil Med. 2012;48(4):651e663.
Letter Regarding “Conservative Treatment of Thumb Base Osteoarthritis: A Systematic Review” other hand, the Villafañe et al4 study that looked at the effect of manual therapy and therapeutic exercise had an effect size of e116.67 with a confidence interval of (e137.55, e95.78) for the reduction of pain. This study demonstrated a large effect with a confidence interval that did not cross 0. The authors reported that the Villafañe et al5 studies “found limited hypoalgesic effects over the contralateral TMC [trapeziometacarpal] joint and reduced pain in the contralateral limb, suggesting a hypothetical bilateral hypoalgesic effect of the intervention” and that the inclusion of studies with effects over the contralateral trapeziometacarpal joint produces an erroneous, low degree of heterogeneity in terms of population. These finding should have been reported with the inclusion of the information that the contralateral control hand did not have carpometacarpal osteoarthritis and the sample size of the studies was small and underpowered. The authors reported that orthosis intervention did not improve hand function. Wajon and Ada6 reported a gain of 6.4 points on the Sollerman test of hand function, Rannou et al7 reported an 11.6% patientperceived reduction in disability score, Weiss et al8
To the Editor: We would like to thank the authors for the undertaking a systematic review for conservative treatment for carpometacarpal osteoarthritis.1 The authors report that they followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).2 The PRISMA systematic review checklist asks authors to describe methods used for assessing the risk of bias.3 The methodological characteristics of the studies were not analyzed using a standardized tool. The PRISMA guidelines also suggest that authors report the results of meta-analysis done with confidence intervals.2 It would have been helpful to have the data synthesized to determine the effect size of the interventions. Effect size confidence intervals calculated can include zero, indicating that it cannot be determined if an effect really exists. For example, in the Villafañe et al3 Kaltenborn mobilization study, the effect size for reduction of pain was calculated to be e0.72 but the confidence interval was (e1.49, 0.34). The effect size was considered small, but because the confidence interval includes zero, we cannot be sure the intervention was effective. On the J Hand Surg Am.
r
Vol. 40, May 2015
Ultrasonography Can Be Used to Assess Phalanx Fractures To the Editor: A 27-year-old man presented with trauma to the ring finger of the left hand, which had occurred one week previously. Pain had suddenly started after he experienced a crush injury during a football game. On physical examination, palpation of the fourth distal phalanx was painful. He could not voluntarily extend the distal phalanx of the fourth digit and he had local swelling. Radiologic evaluation showed a displaced intra-articular fracture of the fourth distal phalanx (Fig. 1A). Ultrasonography (US) was selected as an additional method of assessment and the US image confirmed an avulsed fragment from the distal interphalangeal joint (Fig. 1B, C). The patient was
referred to the hand surgery unit, where he was treated with open reduction internal fixation using Kirschner wires. Phalangeal fractures present as common sports and workplace injuries; they comprise half of all hand fractures. Sports-related injuries are particularly common in the third decade of life, and workrelated injuries in the fifth decade. These fractures are commonly caused by trauma or crush injuries.1 Radiography is routinely performed to evaluate bone injuries. It should be undertaken initially in at least 2 planes centered at the level of the suspected injury, but the possibility of using a noninvasive technique without exposure to ionizing radiation to
FIGURE 1: A X-ray showing the fracture line at the fourth phalanx (arrow). B Longitudinal ultrasonographic view. Insertion of extensor digitorum tendon (thin white arrows) to the avulsed part (outlined arrow) of the distal phalanx. C The axial view designates the fracture line at the fourth distal phalanx (white arrows). D The healthy side. DP, distal phalanx; MP, middle phalanx.
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1057
1058
LETTERS TO THE EDITOR
diagnose a fracture has raised interest in the use of US. Ultrasound performed by an experienced person may be useful in assessing ligament and tendon integrity, evaluating bone cortex integrity, and detecting radiolucent foreign bodies.2 Because plain radiographs provide one-dimensional images, phalanx fractures may sometimes be missed. In addition, in our case study, US revealed a small avulsed bony fragment in close relation to the dorsal lip of the distal phalanx. For this reason, 2-dimensional US images may provide greater accuracy in fracture diagnostics. Ultrasound can be beneficial in diagnosing occult fractures, especially in children,3 when plain radiographs may have been evaluated as normal. This method can also be used as a guide to select surgical methods used to treat fractures. Ultrasound has gained increasing importance in the field of sports medicine and rehabilitation practitioners in identifying structural changes within tissues and joints.4 It should be considered the first-line imaging method
in assessing not only soft tissue injuries but also fractures. Mustafa Turgut Yildizgoren, MD Musa Demirkapi, MD Ayse Dicle Turhanoglu, MD Department of Physical Medicine and Rehabilitation Mustafa Kemal University Medical School Hatay, Turkey http://dx.doi.org/10.1016/j.jhsa.2015.02.022 REFERENCES 1. Bendre AA, Hartigan BJ, Kalainov DM. Mallet finger. J Am Acad Orthop Surg. 2005;13(5):336e344. 2. Williamson D, Watura R, Cobby M. Ultrasound imaging of forearm fractures in children: a viable alternative? J Accid Emerg Med. 2000;17(1):22e24. 3. Neri E, Barbi E, Rabach I, et al. Diagnostic accuracy of ultrasonography for hand bony fractures in paediatric patients. Arch Dis Child. 2014;99(12):1087e1090. 4. Tok F, Özçakar L, De Muynck M, Kara M, Vanderstraeten G. Musculoskeletal ultrasound for sports injuries. Eur J Phys Rehabil Med. 2012;48(4):651e663.
Letter Regarding “Conservative Treatment of Thumb Base Osteoarthritis: A Systematic Review” other hand, the Villafañe et al4 study that looked at the effect of manual therapy and therapeutic exercise had an effect size of e116.67 with a confidence interval of (e137.55, e95.78) for the reduction of pain. This study demonstrated a large effect with a confidence interval that did not cross 0. The authors reported that the Villafañe et al5 studies “found limited hypoalgesic effects over the contralateral TMC [trapeziometacarpal] joint and reduced pain in the contralateral limb, suggesting a hypothetical bilateral hypoalgesic effect of the intervention” and that the inclusion of studies with effects over the contralateral trapeziometacarpal joint produces an erroneous, low degree of heterogeneity in terms of population. These finding should have been reported with the inclusion of the information that the contralateral control hand did not have carpometacarpal osteoarthritis and the sample size of the studies was small and underpowered. The authors reported that orthosis intervention did not improve hand function. Wajon and Ada6 reported a gain of 6.4 points on the Sollerman test of hand function, Rannou et al7 reported an 11.6% patientperceived reduction in disability score, Weiss et al8
To the Editor: We would like to thank the authors for the undertaking a systematic review for conservative treatment for carpometacarpal osteoarthritis.1 The authors report that they followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).2 The PRISMA systematic review checklist asks authors to describe methods used for assessing the risk of bias.3 The methodological characteristics of the studies were not analyzed using a standardized tool. The PRISMA guidelines also suggest that authors report the results of meta-analysis done with confidence intervals.2 It would have been helpful to have the data synthesized to determine the effect size of the interventions. Effect size confidence intervals calculated can include zero, indicating that it cannot be determined if an effect really exists. For example, in the Villafañe et al3 Kaltenborn mobilization study, the effect size for reduction of pain was calculated to be e0.72 but the confidence interval was (e1.49, 0.34). The effect size was considered small, but because the confidence interval includes zero, we cannot be sure the intervention was effective. On the J Hand Surg Am.
r
Vol. 40, May 2015
