Proximal row carpectomy through a palmar approach.

From 1990 to 1994, nine proximal row carpectomies were done through a palmar approach. With an average follow-up of 20 months, seven of the nine patients were completely painfree. Average range of wrist flexion/extension remained unchanged, and average radial/ulnar deviation increased from 25 degrees to 46 degrees . All the patients demonstrated an increase in grip strength in the operated hand. Four cases showed a slight reduction in articular space and subchondral sclerosis in the radiocapitate articulation, in spite of good function. Dynamic studies demonstrated no sign of radiocarpal instability. All the patients were very satisfied with the results and returned to their previous work within 2 months, on average.

Short palmar incision: a new surgical approach for carpal tunnel syndrome.

The authors describe the method of decompression of the median nerve by section of the transverse ligament of the carpus for the treatment of carpal tunnel syndrome using a mini-incision. Use of the method is backed up by an extensive review of the literature concerning the problem of pain in the interthenar region, a complication occurring in wider incisions.

Evaluation of the triangular fibrocartilage complex tears by arthroscopy, arthrography, and magnetic resonance imaging.

Arthroscopic findings in 11 patients with chronic ulnar painful wrist were compared both with arthrographic and magnetic resonance (MR) imaging results to evaluate the accuracy of the former procedure in the detection of triangular fibrocartilage complex (TFCC) lesions. MR imaging and arthrography investigations appeared to be sensitive modalities when compared with arthroscopic findings in TFCC lesions (specificity 100%; sensitivity 82 and 80%). MR imaging can be advantageously employed in the screening of patients suspected of having a TFCC tear, eliminating the necessity of an arthrographic examination. However, MR imaging could not define the exact site of the tear within the degenerate TFCC or detect lesions of the articular cartilage. Arthroscopy offers sure evidence of the site of TFCC lesion and more information about the intraarticular associated causes of chronic ulnar wrist pain such as chondromalacia and synovitis. An added benefit is that many of the pathologies seen can be treated using arthroscopic surgical techniques.

The distally based posterior interosseous island flap for the coverage of skin loss of the hand.

Eight patients with skin coverage of the hand by the distally based posterior interosseous island flap (DBPIIF) are presented. The first web was reconstructed in 6 and the volar and dorsal aspect of the hand in 2 patients. Primary closure of the donor sites has always been possible. An echo Doppler examination is indicated to verify the presence and size of the vessel and the direction of its flow. The dissection of the vascular pedicle, however, is frequently quite complex and time consuming. To better appreciate the cosmetic aspect of the DBPIIF and its donor site, a random study has been undertaken to compare this flap with the radial forearm and the groin flap and their corresponding donor sites. Females have more often preferred the groin flap, whereas doctors preferred the DBPIIF. Reliability, a good aesthetic result at the donor site, and the preservation of the main vessels of the hand are the specific merits of the DBPIIF.

Neurophysiological assessment of the early phases of carpal tunnel syndrome with the inching technique before and during operation.

In 14 patients with early carpal tunnel syndrome, the diagnostic sensitivity of the measurement of the segmental sensory nerve conduction velocity at 1 cm. steps ("inching") was compared with the distal sensory latency and the pre-operative wrist-digit and wrist-palm S.C.V. and with similar measurements made at operation immediately after surgical decompression of the nerve. Before operation, distal sensory latency and wrist-digit S.C.V. were normal in all cases, while wrist-palm S.C.V. was pathological in five patients and inching in all 14 patients. Moreover, inching allowed us to determine the site of the slowing across the carpal tunnel, this being between 1-2 cm. from the distal wrist crease in 57% and between 2-3 cm. in 21% of cases. Focal slowing disappeared immediately after decompression in five patients, as is evident from the intra-operative recordings. Inching is, therefore, the most sensitive diagnostic method in early carpal tunnel syndrome.

MR evaluation of triangular fibrocartilage complex tears in the wrist: comparison with arthrography and arthroscopy.

To evaluate the accuracy of magnetic resonance (MR) in the detection of tears of the triangular fibrocartilage complex (TFCC), 10 consecutive patients with posttraumatic chronic wrist pain were examined with MR, arthrography, and arthroscopy and the results were compared. The MR images of 16 control subjects were also examined to define the MR appearance of the normal TFCC. When compared with arthroscopic findings, both MR and arthrography had two false-negative results (sensitivity, 80%) and no false-positive results. Regarding the sites of the TFCC tears, the findings on MR did not always correlate with the findings on arthrography. In no case was MR able to visualize the cartilaginous lesions visible by arthroscopy. These preliminary results illustrate the ability of MR to assess the integrity of the TFCC and suggest its use as the first imaging technique following plain radiography in the evaluation of patients with chronic posttraumatic pain on the ulnar side of the wrist.

Vascularized nerve graft: a clinical contribution.

The authors present 4 cases of vascularized nerve graft. The results were better than those obtained with traditional grafting. The indication is a rare one, and the experimental results are contradictory. Indications are limited to Volkmann ischemic syndromes, post-actinic lesions of the brachial plexus, infections and finally, post-burning scarring. Nevertheless, traditional nerve grafts remain the treatment of choice for peripheral nerve lesions which cannot undergo direct suturing.

[Blocked metacarpophalangeal joint: etiologic factors and treatment]. / La métacarpo-phalangienne bloquée: facteurs etiologiques et traitement.

The metacarpo-phalangeal is a crucial joint and its stiffness deeply affects hand function. A series of 15 post-traumatic cases resulting in a complete and irreversible block of the joint is presented. Indication for joint release are given and the surgical technique is described. Different approaches are utilized in relationship to associated lesions. Post-operative treatment and percentages of improvement in joint excursion for each digit are reported. All working patients resumed the previous job even in presence of a limited articular gain. Best results where confined uncomplicated post-traumatic cases with crushing of surrounding soft tissues.

The extensor digitorum brevis muscle island flap for soft-tissue loss around the ankle.

The extensor digitorum brevis muscle flap, which has already been suggested as a local flap for the foot, has been applied by us in 2 cases with excellent results. This flap, as with other muscle flaps, provides an excellent bed for the skin graft. Furthermore, because of its width, it allows for covering an area of skin loss 5 X 7 cm in size in areas that are difficult to cover by other reconstructive means. The arch of rotation of this flap allows for coverage of the lateromedial and posterior surfaces of the ankle with no functional loss at the donor site. The relative ease of elevating this flap presents a reasonable justification for its wider application as a single local procedure for skin problems around the ankle.