Ulnar-Side Wrist Pain Management Guidelines: All That Hurts is Not the TFCC!

BACKGROUND: Ulnar-sided wrist pain is a common clinical problem, most often misdiagnosed as triangular fibrocartilage complex (TFCC) injury. It may be frustrating to the patient, as one may end up wearing a wrist splint for an unusually long period, disrupting their routine. PURPOSE: Because of the dilemmas in the diagnosing the cause of ulnar-sided wrist pain, various algorithms have been suggested but it is an individual's choice to do a systematic assessment and follow in their routine clinical practice. We propose the 'storey concept' for examining the ulnar side of the wrist, with ulnar styloid as the reference point. The lower storey identifies the pathologies of the DRUJ, the intermediate storey identifies the pathologies of the radiocarpal joint and the upper storey identifies the pathologies of midcarpal and carpometacarpal joint. CONCLUSION: Also, it is important to ramify the cause of pain into stable or unstable wrist, with or without arthritis, as this will guide us in managing the pain arising from distal radioulnar joint. In addition to methodical clinical examination, ideal radiographs and high-resolution MRI are critical to diagnose wrist pathologies. The role of wrist arthroscopy has consistently increased, and complements in both diagnosis and treatment of wrist pain especially in ambiguous situations.

Ulnar Nerve Innervation to Triceps: A Cadaveric Study and a Technical Note on Partial Triceps to Biceps Transfer.

BACKGROUND: The loss of elbow flexion is a routinely encountered problem in clinical practice. There is no literature on ulnar nerve innervation to triceps in addition to the radial nerve which is dual nerve innervation to triceps in the Indian population. We intend to study the incidence of ulnar nerve innervation to the medial head of triceps in Indian population and also the clinical feasibility of transfer of long and medial head of triceps tendon to biceps around the medial aspect of humerus. MATERIALS AND METHODS: A cross-sectional study was conducted using 32 fresh-frozen skeletally mature cadavers of Indian origin. The possible contribution of the ulnar nerve to medial head of triceps in addition to the radial nerve was recorded. The arm length, the distance where the ulnar nerve pierces the medial intermuscular septum from medial epicondyle; the distance of the ulnar nerve fascicle from the medial epicondyle was also measured. RESULTS: The incidence of ulnar nerve innervation to the medial head of triceps was 43.8%. Mean arm length was 29.13 cm. Mean distance where the ulnar nerve pierced the medial intermuscular septum from medial epicondyle was 9.93 cm. Mean distance of the ulnar nerve branch to the triceps from medial epicondyle was 8.01 cm. CONCLUSION: This study reveals the presence of dual nerve innervation to triceps in 43.8% of the Indian population. The clinical implication would be to look for the possible contribution of the ulnar nerve fascicle to the medial head of triceps, which will help us to include the medial head along with the long head of triceps while performing partial triceps-to-biceps tendon transfer, and the other use would be as a donor fascicle when performing a nerve transfer.

Assessment of Usefulness of Anthropometric Data for Predicting the Scaphoid and the Screw Length: A New Technique.

BACKGROUND: Headless screw is frequently used for scaphoid fracture fixation. Aim of the study was to assess the correlation between the axial length of the scaphoid and the axial length of the middle phalanx of index, middle, ring and little finger so as to provide an indirect method to assess the length of the scaphoid and thereby the length of the screw. METHODS: Thirty five fresh frozen cadavers with seventy wrists and hands were dissected. The age, sex and side were recorded. The axial length of the scaphoid, axial length of the middle phalanx of index, middle, ring and little finger were recorded and a correlation was assessed. Five cadavers were randomly selected and radiographs of the hand were done. Pearson coefficient correlation was assessed between the axial length of the middle phalanx of ring finger on a radiograph and actual length of middle phalanx. RESULTS: A significant positive correlation was noted between the axial length of the scaphoid and the axial length of the middle phalanx of ring finger (r = 0.646), also a positive correlation between the axial length of middle phalanx of ring finger on a radiograph and the axial length of the scaphoid measured by vernier caliper (r = 0.91). CONCLUSIONS: A preoperative radiograph of the wrist with hand will help us indirectly assess the axial length of the scaphoid by measuring the axial length of the middle phalanx of ring finger.

An epidemiological study of traumatic brachial plexus injury patients treated at an Indian centre.

BACKGROUND: Epidemiological studies on traumatic brachial plexus injuries are few and these studies help us to improve the treatment, rehabilitation of these patients and to allocate the resources required in their management. Epidemiological factors can vary in different countries. We wanted to know the situation in an Indian centre. MATERIALS AND METHODS: Data regarding age, sex, affected side, mode of injury, distribution of paralysis, associated injuries, pain at the time of presentation and the index procedure they underwent were collected from 304 patients. Additional data like the vehicle associated during the accident, speed of the vehicle during the accident, employment status and integration into the family were collected in 144 patients out of the 304 patients. RESULTS: Road traffic accidents accounted for 94% of patients and of the road traffic accidents 90% involved two wheelers. Brachial plexus injury formed a part of multitrauma in 54% of this study group and 46% had isolated brachial plexus injury. Associated injuries like fractures, vascular injuries and head injuries are much less probably due to the lower velocity of the vehicles compared to the western world. The average time interval from the date of injury to exploration of the brachial plexus was 127 days and 124 (40.78%) patients presented to us within this duration. Fifty-seven per cent had joined back to work by an average of 8.6 months. It took an average of 6.8 months for the global brachial plexus-injured patients to write in their non-dominant hand.