Arthroscopic Resection of Volar Ganglion of the Wrist Joint

PURPOSE: To evaluate the results of arthroscopic resection of volar ganglion of the wrist. MATERIALS AND METHODS: Nine patients who had arthroscopic resection of volar ganglion of wrist were evaluated. Using 3-4 poral as a viewing portal, volar ganglion was debrided through the radioscaphocapitate (RSC) ligament and long radiolunate (LRL) ligament using a resector inserted from the 1-2 or 4-5 portal. We evaluated the incidence of relapse, the time to postoperative disappearance of pain, surgical complications, and intra-articular derangements. RESULTS: Eight patients had synovitis around radial styloid process. Three patients had capsular tear between RSC ligament and LRL ligament. There was no relapse at an average follow-up of 15 months. The pain felt during daily activities subsided at 2.5 months after operation in 9 patients. One patient had partial injury of the median nerve causing persistent paresthesia. All were satisfied for the postoperative scars. CONCLUSION: Arthroscopic resection is a reliable option with good cosmetic results for the treatment of volar ganglion of the wrist.

Management of the Posttraumatic Neuralgia of the Peripheral Nerve by External Neurolysis

PURPOSE: To evaluate the results of the external neurolysis of the scarred peripheral nerves present with the posttraumatic neuralgia refractory to the conservative treatment for at least 6 months with or without vein wrapping and/or free fat graft to prevent scar reformation. MATERIALS AND METHODS: In 8 patients with posttraumatic neuralgia of the peripheral nerve unresponsive to conservative treatment for at least 6 months, only neurolysis was done in 6 cases. Vein wrapping with free fat graft was concomitantly added after neurolysis in one case and free fat graft was added in the other case. The inclusion criteria were neuralgia felt anatomically along the affected nerve, positive Tinel sign at the scarred site and aggravation of pain with passive motion of the adjacent joint. Affected were digital nerves (two cases), ulnar nerve at the wrist (one case), median nerve (one case), peroneal nerve around knee (one case), posterior tibial nerves (two cases) and plantar nerve (one case). Patients were assessed for the disappearance of neuralgia and Tinel sign and subjective satisfaction with VAS (no pain, 0 and no change or aggravated, 10 compared to contra-lateral side) RESULT: Neuralgia was absent in four cases and persisted in four cases. Average VAS was 5.8 (0~10). According to the degree of the scarred surroungings, neuralgia was persisted after only neurolysis in four cases of the severely scarred 5 cases, but in one case having free fat graft added, neuralgia was absent. In partially scarred two cases, neurolysis with or without additional procedures (free fat graft and vein wrapping) brought the same result of VAS. In one case of good surroundings, neuralgia was absent after neurolysis. Tinel sign was absent in 4 cases where neuralgia had disappeared. CONCLUSION: Prevention of re-adhesion after neurolysis seems to be very important to yield good results. Vein wrapping and/or free fat grafting may be effective methods to be applicable if the adjacent tissue looks scarred

Management of the Comminuted Fractures of the Ulnar Head and Neck Combined with Distal Radius Fractures by Darrach Procedure and Tenodesis of Extensor Carpi Ulnaris

PURPOSE: To evaluate the surgical results of distal radioulnar fractures managed by open reduction and internal fixation for the fractures of the distal radius and excision of the fractured fragments and ECU tenodesis for the comminuted fractures of ulnar head and neck. METHODS: Six cases of combined fractures of the distal radius and ulna were enrolled. Distal radius fractures were fixed by ORIF with AO locking plate without bone graft. The comminuted fragments of distal ulnar head and neck were excised and the tenodesis using half strip of ECU was added to stabilize the proximal ulnar stumps. After immobilization for 6 weeks, active ROM exercise started. The change of radial inclination and volar tilt, the ulnar shift and collapse of carpal bone and ulnar impingement were investigated with simple X-ray. Patients were assessed with residual subjective symptoms and modified Mayo wrist score (MMWS). All were female and average age was 68(58~75) years. Average follow up was 23(10~50) months. RESULTS: Resting pain was absent in all patients but heavy lift made them feel weakness and discomfort intermittently. All patients returned to the normal daily activities except one patient handicapped by hemiplegia. The average range of motion and grip power was 89% and 85% compared to the contralateral side respectively. The average MMWS was 87(75~95). The postoperative loss of the reduction of the distal radius was not observed in follow up X-ray. CONCLUSION: ORIF of distal radius fractures associated with the excision of the distal ulnar fragments and stabilization procedure using half strip of ECU may be one good method for the treatment of the fractures of the distal radius combined with the comminuted distal ulnar fractures difficult to be managed by ORIF. The intermittent weakness felt in this method made it not suitable in young active patient doing heavy work. AO locking plate was strong enough to maintain reduction until bone union.

Improvement of the Elbow Function with Early Mobilization and Rigid Fixation of Coronoid Fracture by Tension Band Technique

PURPOSE: We wanted to evaluate the surgical results of early mobilization after rigid fixation of small coronoid fracture using the tension band technique MATERIALS AND METHODS: Eight cases of coronoid fracture were fixed with the tension band technique and using K-wire and wire through the medial approach. All the cases were Regan-Morrey type 2. According to O'Driscoll, they were classified as 5 cases of the tip type (subtype 2) and 3 cases of the anteromedial type (1 case of subtype 2, and 2 case of subtype 3). The associated collateral ligament injuries (6 cases) and radial head/neck fractures (4 cases) were managed simultaneously. After immobilization for 5~7 days, active ROM exercise with a fitted hinge brace started and continued till postoperative 6 weeks. The patients were assessed for pain, ROM and functional disability using the Mayo elbow performance score (MEPS) at an average of 11 months (range: 6~28 months). The ulnar nerve symptoms were also investigated. RESULTS: We observed solid union in all the coronoid fractures without hardware failure. An average of 2.2 wires (range: 2~4) were used. The mean extension was 3degrees (range: 0degrees~25degrees), the mean flexion was 137degrees (range: 130degrees~140degrees), the mean pronation was 69degrees (range: 45degrees~90degrees) and the mean supination was 78degrees (range: 45degrees~90degrees). The mean MEPS was 96 (range: 65~100). Ulnar nerve symptoms occurred at postoperative one day and persisted in one patient with the terrible triad of taking radial head excision and residual medial instability. CONCLUSION: The tension band technique uses easily obtained, economic K-wires and the wire was strong enough to permit early elbow ROM exercise and the technique might improve the elbow function. It was especially useful for fixation of multiple small fragments.

Surgical Treatment of the Fracture of the Scapular Body

PURPOSE: We wanted to evaluate the results of surgical treatment for fracture of the scapular body MATERIALS AND METHODS: The subjects of this study were seven patients with fracture of the scapular body and all these patients were managed surgically. We considered the operative indications as being 100% translation of the lateral border, or 25 degrees of angular deformity of the glenoid, or 1cm medialization or the variant of the double disruption of the superior scapular suspensory complex. There were five males and two females, and their ages ranged between 40 and 58 years (mean age: 49) with average follow up of 11 months (6~24 months). Two patients sustained multiple fractures of the ribs and spines. The surgical results were evaluated according to the subjective satisfaction, the UCLA score and the Korean shoulder score. RESULTS: The mean UCLA score was 29 (17~33) and the mean Korean shoulder score was 86 (63~94). The self assessment for subjective satisfaction was 7.7 (4~9). There were two complications; one case of screw pull-out without the loss of the fracture fixation and the other case with screw penetration of the glenoid cavity. CONCLUSION: Surgical treatment may be effective for the management of severely displaced fracture of the scapular body in order to prevent the impairment of the shoulder function caused by the altered glenohumeral and scapulothoracic kinematics.