Exposures of the wrist and distal radioulnar joint.

This article reviews the superficial, skeletal, and ligamentous anatomy of the wrist. Standard and alternative exposures of the wrist joint and the distal radioulnar joint are discussed, emphasizing the importance of avoiding nerve injury. Standard exposure of the wrist joint is used in the treatment of carpal ligament injuries, fractures, and dislocations. Case presentations illustrate these techniques.

Carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy in the upper extremity. The condition is responsible for substantial annual costs to society, both in terms of lost productivity and the costs of treatment. Accurate diagnostic criteria, the selection of treatment strategies based on high-level evidence, and outcomes data have been inconsistent despite the prevalence of the condition. The increased awareness of the need for evidence-based practice guidelines has, however, yielded important data to guide treatment of CTS. Evidence-based guidelines for diagnosis and treatment have been developed and should direct the treatment of CTS.

Arthroscopic treatment of ulnar impaction syndrome.

Ulnar impaction syndrome occurs in the setting of a central traumatic or degenerative defect in the triangular fibrocartilage complex in patients with ulnar positive variance. Chondral and subchondral edema, mechanical impingement of the articular disc, and chondromalacia of the distal ulna, proximal lunate, and proximal triquetrum produce symptoms with activity that do not improve with rest. Decreasing ulnocarpal load-sharing across the wrist with recession of the distal ulna is necessary to relieve symptoms in the majority of patients. Arthroscopic treatment with triangular fibrocartilage complex debridement and arthroscopic ulnar wafer resection is an effective treatment for ulnar impaction syndrome. It affords a single-stage, minimally invasive approach, with similar efficacy and fewer complications than open wafer resection or ulnar shortening osteotomy.

The dorsal approach to silicone implant arthroplasty of the proximal interphalangeal joint.

Silicone implant arthroplasty (SIA) has been an effective alternative in the treatment of arthritic conditions of the proximal interphalangeal (PIP) joints since its introduction into surgical practice in the early 1960s. Patients with post-traumatic, degenerative, and rheumatoid arthritis all may be candidates for PIP joint SIA. The indications for SIA of the PIP joint include pain, limited joint mobility, and angular deformity of the joint with underlying articular destruction. Contraindications include ankylosis of the joint due to bony or soft-tissue restrictions, infection, inadequate soft-tissue support for coverage, absence of flexor and/or extensor tendon function, and considerable periarticular bone loss in the proximal and middle phalanges. Proximal interphalangeal joint SIA can be accomplished by dorsal, volar, or midaxial approaches. The dorsal approach has the advantages of relative technical ease, excellent visibility of the articular surfaces for preparation of the implant canals, access to the extensor mechanism for correction of central slip abnormalities, and preservation of the collateral ligaments. The surgical technique is outlined and includes handling of the extensor mechanism and central slip attachment, mobilization of the collateral ligaments, joint surface resection, preparation of the bony canals, implant sizing, implant insertion, and repair of the soft tissues. Pearls and pitfalls of the technique are outlined. Early postoperative mobilization with hand therapy is essential but must include protection of the repaired extensor apparatus. Complications include bony changes, implant failure, recurrent angular deviation or swan-neck deformity, particulate synovitis, and rarely, infection. Complications related to implant failure are most often managed with implant replacement or arthrodesis; those related to poor mobility, angular deformity and tendon imbalance, pain, or infection are managed by arthrodesis. Although SIA of the PIP joint has a relatively high degree of success when measured both subjectively and objectively, careful patient selection is important for achieving desirable results.