Surgical findings in the treatment of Dupuytren's disease after initial treatment with clostridial collagenase (Xiaflex).

We investigated the difficulty of surgical fasciectomy after previous treatment with clostridial collagenase injection. The 35 clinicians who had participated in the initial trials of this injection were contacted via email. Twenty-eight responded, nine of whom reported on 15 patients. Most (seven of nine) felt there was no significant distortion of anatomy and rated the level of technical difficulty as equivalent to a primary Dupuytren's fasciectomy at the observed degree of contracture (nine of 15 cases). One respondent (four of 15 cases) reported significantly more difficulty and grossly distorted anatomy. One surgical complication, a wound dehiscence, was reported.

In vivo motion of the scaphotrapezio-trapezoidal (STT) joint.

It has previously been shown that the articulation of the scaphotrapezio-trapezoidal (STT) joint can be modeled such that the trapezoid and trapezium are tightly linked and move together on a single path relative to the scaphoid during all directions of wrist motion. The simplicity of such a model is fascinating, but it leaves unanswered why two distinct carpal bones would have a mutually articulating surface if there were no motion between them, and how such a simplistic model of STT joint motion translates into the more complex global carpal motion. We performed an in vivo analysis of the trapezoids and trapeziums of 10 subjects (20 wrists) using a markerless bone registration technique. In particular, we analyzed the centroid spacing, centroid displacements, kinematics, and postures of the trapezoid and trapezium relative to the scaphoid. We found that, on a gross level, the in vivo STT motion was consistent with that reported in vitro. In addition, we found that the magnitude of trapezoid and trapezium motion was dependent upon the direction of wrist motion. However, we also found that when small rotations and displacements are considered there were small but statistically significant relative motions between the trapezoid and trapezium (0.4 mm in maximum flexion, 0.3 mm in radial deviation and at least 10 degrees in flexion extension and ulnar deviation) as well as slight off-path rotations. The results of this study indicate that the STT joint should be considered a mobile joint with motions more complex than previously appreciated.

Nerve injuries of the elbow, wrist, and hand in athletes.

Upper extremity compression neuropathies are fairly rare in athletes. Initially, most can be managed conservatively. These conditions can follow direct contusion of the tissues that overlay these peripheral nerves or can result from vigorous, repetitive, athletic activity leading to tissue swelling and ischemia with nerve compression symptoms. A complete history and physical examination, including a neurologic examination, should be paramount when treating athletes with upper extremity injuries. Early diagnosis and treatment with conservative measures such as splinting, rest, activity modification, and medications can afford the athlete an earlier return to sports. Surgery can be employed when conservative treatment fails and a specific diagnosis has been ascertained.

Thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is an often misdiagnosed cause of neck, shoulder, and arm disability. Neurovascular compression may be seen in the interscalene triangle, costoclavicular space, or posterior to the pectoralis minor, although any cause of abnormalities of shoulder girdle alignment may cause a localized area of brachial plexus compression. Nerve compression in this way may lead to upper extremity weakness, pain, paresthesias, and numbness. A careful and detailed medical history and physical examination are essential to proper identification of thoracic outlet syndrome, which remains primarily a clinical diagnosis. Diagnostic testing may differentiate other causes of pain or neurologic symptoms of the upper extremity from TOS. Clinical management is often challenging.

Median nerve injury in an expert skier: a case report.

A 20-year-old expert skier presented with sustained ulnar arterial, median nerve, and multiple flexor tendon injuries. Surgery was performed repairing the nerve, artery, and tendons, and in subsequent follow-up, the patient had an excellent postoperative result.

The effect of wrist guards on bone strain in the distal forearm.

There are increasing epidemiologic and biomechanical data suggesting that wrist guards are effective in preventing wrist injuries in snowboarders and in-line skaters. However, there have been few studies designed to determine how they function. In this study we explored the load-sharing function of wrist guards at subfailure loading levels. To do so, we measured bone strain in the distal radius, distal ulna, and midshaft of the radius in cadaveric forearms with and without two types of commercially available wrist guards. We also measured construct stiffness and energy absorption during testing. Our most significant findings were that dorsal and volar distal radius bone strain were reduced with both wrist guards, and wrist guards increased energy absorption. We also found a reduction in dorsal distal ulnar bone strain, but only with the one guard in which the volar plate was elevated off the heel of the hand. In our loading configuration, wrist guards did not increase bone strain at the radial midshaft. These findings provide insight into how wrist guards protect the wrist: during low-energy falls they function partly by load-sharing, as well as by absorbing impact energy.

Traumatic nerve injuries about the elbow.

Although not common, nerve injuries about the elbow occur because of the proximity of the three upper extremity nerves or because of the relationship of the median, ulnar, and radial nerves to the bony and soft-tissue structures about the elbow joint. Nerve injuries at and about the elbow joint occur more frequently with fractures than with any other kind of trauma. Nerve injuries may be found with periarticular fractures, dislocations, gunshot wounds, lacerations, and other iatrogenic causes.

The results of revision carpal tunnel release following previous open versus endoscopic surgery.

This study compared the outcomes of revision open carpal tunnel release following previous open versus endoscopic release to determine whether revision surgery has different results based on the type of initial surgical treatment. Thirty revision carpal tunnel releases were performed in 13 wrists that had previous endoscopic release and in 17 wrists with prior open release. At a follow-up visit an average of 30 months after surgery, self-assessment questionnaires demonstrated improved or complete symptom relief in 77% of the postendoscopic release group versus 47% in the previous open release group. Combining both groups, 18% of workers' compensation patients improved after revision surgery compared with 84% of those with conventional insurance (p < .05). Patients having persistent or recurrent symptoms following a previous endoscopic carpal tunnel release have a greater chance of symptom improvement or resolution compared with patients who had previous open carpal tunnel surgery. Our results support the observation that a higher incidence of incomplete release of the carpal tunnel is found with endoscopic surgery than with open release.

Primary care of hand and wrist athletic injuries.

Athletic injures to the hand and wrist can range from simple sprains to severe fractures or soft-tissue disruptions that can permanently threaten the normal function of the extremity. This article deals with some of the more commonly noted sports-related injures to the hand and wrist to help the team physician make the correct diagnosis and establish the most effective treatment plan, so that the athlete may achieve maximum results and ultimately return to full participation in their sport.

Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex.

Over a 4-year period, 160 wrist arthroscopies were performed at 1 institution. Ninety-seven patients had central or nondetached ulnar peripheral tears of the triangular fibrocartilage complex (TFCC). All these patients underwent debridement with an arthroscopic shaver. Thirteen of the 97 had persistent pain in the TFCC region for more than 3 months after surgery. At an average of 8 months after failed arthroscopic debridement of the TFCC, all 13 patients underwent a 2-mm-long ulna-shortening osteotomy with fixation by a 3.5-mm 6-hole dynamic compression plate. At follow-up examination (an average of 2.3 years later), 12 of the 13 had complete relief of pain at the ulnar side of the wrist. One patient continued to complain of pain with moderate to heavy activity use of her hand. Four of the 13 had postoperative complications: 1 had traumatic pull-out of the screws requiring reinsertion and distal radius bone graft, 1 had nonunion at 4 months after surgery that required iliac crest bone graft, and 2 had pain necessitation hardware removal. All 4 of these patients had no further problems at final follow-up evaluation. There was no statistically significant difference between the arthroscopic debridement alone cohort and the arthroscopy/ulna-shortening subgroup relative to ulnar variance or incidence of associated lunotriquetral ligament tears. On the basis of these findings the authors recommend a 2-mm-long ulna-shortening osteotomy for patients whose previous arthroscopic debridement for central or nondetached peripheral TFCC was unsuccessful in eliminating ulnar-sided wrist pain.

Disorders of the distal radioulnar joint.

Disorders of the distal radioulnar joint can be classified into functional abnormalities based on instability, incongruity of the joint surface, impaction, and isolated triangular fibrocartilage complex tears. Knowledge of the type of lesion aids in selecting the treatment option best suited to correcting each problem. This review begins by summarizing the anatomy of the distal radioulnar joint. It then examines the various clinical problems that may arise in this complicated anatomic area and outlines the different surgical and nonsurgical options available to treat these disorders. The most important aspect in treatment of disorders of the distal radioulnar joint is early recognition, followed by prompt appropriate surgical or nonsurgical management.

Radial tunnel syndrome.

Intermittent compression of the PIN within and just distal to the anatomic region known as the radial tunnel is responsible for a constellation of signs and symptoms known as radial tunnel syndrome. The five structures commonly implicated as possible offenders include the fibrous adhesions between the brachialis and brachioradialis, the leash of Henry, the fibrous edge of the ECRB, the arcade of Fröhse, and fibrous bands associated with the supinator muscle. The condition is dominated by pain centered over the radial tunnel, whereas muscle weakness, if present, is clinically insignificant. Specific attention to the character and point of maximal tenderness, worsening of pain on the provocative middle finger extension and resisted supination tests, and relief of symptoms following a radial tunnel anesthetic block help diagnose RTS. Electrodiagnostic testing presently has limited use in diagnosing RTS. The management of RTS includes activity modification and other conservative measures. Most patients, however, eventually require surgery, in which routine release of all potential constricting structures is performed. Although several surgical approaches are available, the brachioradialis-ERCL interval approach is one that has been very satisfying in our hands.

Influence of steroid injection on ligament healing in the rat.

The effect of a single local injection of long acting corticosteroid on the healing of acute rat medial collateral ligament injuries was studied. The medial collateral ligaments of 81 adult female rats were exposed surgically. In 32 rats, the ligament was transected sharply, the overlying muscle was closed, and a human equivalent dose of dexamethasone was injected under the muscle layer, bathing the injured ligament. The identical operation with no corticosteroid injection was done in 32 additional rats: in the remaining 17 animals, the incision was closed without ligament transection or injection. The rats were divided into 3 groups of 25. Each group consisted of 10 rats that were injected, 10 that were not injected, and 5 that underwent sham operations. One group was euthanized 6 days after surgery, 1 group after 10 days, and 1 group after 20 days. Histologic evaluation and biomechanical testing were performed for each subgroup. A cellular pathologist examined a smaller group of 6 rats (2 from each group) for histologic changes 40 days after surgery. No histologic differences were noted between the injected and noninjected ligaments 6, 10, or 20 days after injury. At 40 days, the injected specimens showed a slightly more mature crimp pattern than the noninjected specimens. Mechanical testing demonstrated no significant difference in ultimate load or ultimate stress between the injected and noninjected groups. There were no detrimental effects of a single dose administration of dexamethasone on the histologic appearance or biomechanical strength of healing rat medial collateral ligaments.

Distal radius fractures: concepts and complications.

Distal radius fractures are one of the most common types of injuries treated by an orthopedic surgeon. The overall results may not be as favorable as once thought. As a distinct subgroup, the young adult deserves special consideration. Management of distal radius fractures in these patients is difficult due to the higher energy involved, amount of comminution, and associated soft tissue damage. Functional outcome has been best when an anatomical reduction has been achieved. Many surgical options are available: external fixation, percutaneous pin fixation and open reduction are the mainstays. The complications may be minimized with careful attention to and knowledge of the techniques used and early intervention when closed treatment fails.

Anatomy of the palmar cutaneous branch of the median nerve: clinical significance.

A detailed anatomic, histologic, and immunohistochemical study of the palmar cutaneous branch of the median nerve (PCBMN) and its distal arborization was undertaken on 12 fresh human cadaveric hands. Small unmyelinated fibers terminated in the superficial loose connective tissue of the transverse carpal ligament. There were no nerve fibers detected in the deep, dense collagen aspect of the ligament. Based on these findings, during open carpal tunnel release, the skin incision should be placed along the axis of the ring finger to avoid injury to the superficial branches of the PCBMN. When open release is used, the very small terminal branches in the loose tissue of the ligament will be transected; this may in part be responsible for postoperative soft tissue pain. For endoscopic releases, some risk for transection of the main trunk of the PCBMN at the proximal incision exists. Repeated passes of the endoscopic knife should be avoided in an attempt to limit damage to the small fibers in the superficial aspect of the ligament.

Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy.

Fifty consecutive patients who had a history and clinical findings consistent with internal derangement of the wrist were prospectively entered into a study to compare the findings of triple-injection arthrography with those of arthroscopy of the wrist with use of three portals. Twenty-six patients were men, and twenty-four were women. They had an average age of thirty-six years (range, eighteen to seventy years). The average duration of symptoms in the wrist was eight months (range, one to twenty-four months). The arthrograms of the wrist, which included cineradiographs, were all made and evaluated by the same radiologist. The arthroscopic evaluation of the wrists was performed by two hand surgeons who had previous knowledge of the arthrographic findings. The abnormal findings included in this study were limited to those that should be detectable with both arthrography and arthroscopy. These were full-thickness tears of the scapholunate ligament, the lunotriquetral ligament and the triangular fibrocartilage. The findings of arthrography were normal in eighteen wrists, demonstrated a single lesion in twenty-one, and demonstrated multiple lesions in eleven. Twelve wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and eighteen, a tear of the triangular fibrocartilage. The arthroscopic findings were normal in six wrists, demonstrated a single lesion in twenty-five, and demonstrated multiple lesions in nineteen. Twenty-two wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and thirty, a tear of the triangular fibrocartilage. When compared with arthroscopy of the wrist, the sensitivity, specificity, and accuracy of triple-injection cinearthrography in detecting tears of the scapholunate ligament, lunotriquetral ligament, and triangular fibrocartilage, as a group, were 56, 83,and 60 per cent. Although arthrography of the wrist is a well accepted diagnostic modality in the evaluation of pain in the wrist, this study suggests that normal arthrographic findings do not necessarily rule out the possibility of internal derangement of the wrist.

Lumbar spinal stenosis: a review.

Lumbar spinal stenosis can usually be identified after a thorough history and physical examination. Most individuals with this condition are successfully treated by non-operative means. Invasive radiologic studies and surgery are reserved for those patients who fail to respond to conservative measures. In these select cases, predictably good results can be expected from lumbar decompression.

Diagnostic imaging and arthroscopy for chronic wrist pain.

This article discusses a current overview of the diagnostic imaging techniques available to the orthopaedic surgeon trying to establish an etiology of chronic wrist pain. A discussion on the use of arthroscopy in conjunction with or as a replacement for these imaging techniques is also presented. A discussion of the advantages and disadvantages of each of these techniques is provided to try to aid the reader in establishing a cost-effective and efficient treatment algorithm for these difficult diagnostic dilemmas.

Carpal tunnel syndrome. Etiology and endoscopic treatment.

Carpal tunnel syndrome involves classic symptoms of numbness and paresthesias in the radial three and one-half digits, most frequently nocturnal, with pain associated with this anatomic distribution. Thenar weakness and autonomic dysfunction occurs late in these patients and are usually seen in advanced cases. The wrist flexion test and local percussion sensitivity tests done on physical examination can be helpful in determining and confirming the diagnosis of carpal tunnel syndrome. The likelihood that operative treatment will be required for resolution of symptoms is heightened if the patient is involved in daily manual repetitive activities of the hand or wrist. Surgical decompression can be accomplished by either a limited open or new endoscopic carpal tunnel release techniques. Currently, the advantages and disadvantages present in both procedures and careful controlled studies conducted in a prospective and randomized fashion will be required to further delineate the indications for either procedure. Carpal tunnel release remains an operative procedure with the most predictable outcome with relief of symptoms for the patient.