Considerations for the treatment of the injured athlete.

This article discusses the significance that contusions, fractures, or ligament injuries (involving the small bones, joints, and soft tissues of the forearm, wrist, or hand) can have on the athlete. The concern for proper management of upper-extremity injuries is addressed in order to decrease the possibility of long-term function consequences for the athlete.

Safe carpal tunnel release via a limited palmar incision.

Despite its demonstrated advantages in postoperative recovery, endoscopic carpal tunnel release has not been adopted by most surgeons because of the associated complications of neurovascular injury. A technique of carpal tunnel release is presented that utilizes a 1.0 to 1.5-cm palmar incision and a specially designed carpal tunnel "tome." Any aberrant anatomy of adjacent neurovascular structures may be identified under direct vision. Anatomic dissection in 28 cadaveric specimens following the procedure showed complete decompression of carpal tunnel and preservation with safe margins of the palmar cutaneous branch and thenar motor branch of median nerve, ulnar artery and nerve, and superficial palmar arch. Clinical experience with the technique in two centers consisted of 525 patients and 694 hands over a 29-month period. The great majority of patients derived complete (72.6 percent) or near-complete (19.6 percent) symptomatic relief from the procedure, and two complications (0.29 percent) of median nerve lacerations occurred. Postoperative incisional and pillar tenderness and grip, key pinch, and three-point pinch strengths were comparable with those in published series of endoscopic carpal tunnel release. We conclude that this technique of carpal tunnel release combines the simplicity and safety of traditional open release and the reduced tissue trauma and improved postoperative recovery of the endoscopic modality.

The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome.

The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence between the median nerve and overlying transverse carpal ligament and surgical scar. This retrospective study reviews 62 hands in 58 patients (46 non-workers' compensation and 16 workers' compensation) with recurrent symptoms after failed open carpal tunnel release who underwent revision carpal tunnel decompression and in whom a hypothenar fat pad flap was used. The follow-up period averaged 33 months. Patient satisfaction was 6 in the non-workers' compensation group and 4 in the workers' compensation group. Average time to return to work for the non-workers' compensation group was 12 weeks, compared to 37 weeks for the workers' compensation group. Study results indicate that the hypothenar fat pad flap produces excellent results in procedures designed to alleviate recalcitrant idiopathic carpal tunnel syndrome.

Arthrodesis of the wrist for post-traumatic disorders.

We retrospectively reviewed the records of eighty-nine consecutive patients (ninety wrists) who had had a total arthrodesis of the wrist for the treatment of a post-traumatic disorder at one center. Fifty-six patients (fifty-seven wrists) had the arthrodesis with plate fixation, and thirty-three patients (thirty-three wrists) had the arthrodesis with a variety of other techniques. The average age of the patients at the time of the arthrodesis was forty-two years, and the dominant wrist was treated in forty-two patients. Fifty-six (98 per cent) of the fifty-seven wrists that had been fixed with a plate had a successful union at an average of 10.3 weeks postoperatively. Twenty-seven (82 per cent) of the thirty-three wrists that had been treated with other methods had a successful union at an average of 12.2 weeks postoperatively. The difference in the rates of union between the wrists fixed with a plate and those treated with alternative techniques was significant (p = 0.009; Fisher exact test). A total of thirty-nine complications were associated with twenty-nine (51 per cent) of the fifty-seven arthrodeses with plate fixation. Sixteen (41 per cent) of the complications (thirteen wrists) resolved with non-operative treatment. Twenty-six (79 per cent) of the thirty-three arthrodeses with alternative methods of fixation were associated with a total of twenty-nine complications. Twenty-three (79 per cent) of those complications (twenty wrists) resolved with non-operative treatment. The difference between the rate of complications associated with the arthrodeses with plate fixation and that associated with the arthrodeses with alternative methods of fixation was significant (p = 0.03; Fisher exact test).

Carpal tunnel release with a small palmar incision.

The use of carpal tunnel tome with a small palmar incision to release the transverse carpal ligament is discussed. The technique is fully illustrated, and the authors early clinical experience is reviewed.

Recalcitrant carpal tunnel. The hypothenar fat pad flap.

Open decompression of the median nerve generally is so effective that little is mentioned of the surgical treatment options for recalcitrant or unrelieved carpal tunnel syndrome. The hypothenar fat pad flap has been shown to be a reliable local source of well-vascularized adipose tissue that can be used for coverage of the median nerve during re-exploration of recurrent or persistent idiopathic carpal tunnel syndrome. The hypothenar fat pad flap is a technically simple procedure that allows the fat pad to be mobilized easily and placed across the palm as a barrier between the nerve and the radial leaf of the transverse carpal ligament, effectively preventing median nerve readherence. This flap hopefully will improve the tissue environment for the median nerve, permitting it to have normal excursion during wrist motion. Our results to date have been better than previously described for other techniques. We believe the hypothenar fat pad flap should be considered in the hand surgeon's armamentarium for recalcitrant idiopathic carpal tunnel syndrome.

Upper extremity function after wrist arthrodesis.

Several studies have examined the normal range of wrist motion used to accomplish activities of daily living. Little information is present, however, on what functional limitations might be experienced by patients actually undergoing formal wrist arthrodesis. This study undertook comprehensive functional evaluation of 23 patients who underwent wrist arthrodesis for post-traumatic conditions. Follow-up evaluation averaged 54 months and consisted of a clinical questionnaire, the Jebsen Hand Function Test, and a functional rating devised by Buck-Gramcko/Lohmann. Fifteen of the 23 patients returned to their original jobs, and all patients noted that although the vast majority of tasks could still be performed, these tasks were undertaken in a modified fashion. The most difficult daily tasks for patients with a wrist arthrodesis to perform involved perineal care and manipulating the hand in tight spaces. The Jebsen Hand Function Test demonstrated a 64% task completion rate with the fused wrist compared to a 78% task completion rate for the normal wrist. The Buck-Gramcko/Lohmann evaluations demonstrated an average score of 8.3 out of a possible 10. Patients who have undergone wrist arthrodesis can accomplish most activities of daily living and other functional requirements, although some adaptation to accomplish these tasks is required.

Philosophy of the treatment of athletes.

There is a proliferation of sports medicine physicians whose training is largely in the management of such athletically debilitating conditions as knee ligament and meniscus tears. Physicians with responsibility for the management of the full spectrum of sports-related conditions, including upper extremity injuries, may actually be a disservice to the athlete who may receive less than expert care for his or her injured wrist or hand.

A biomechanical comparison of techniques of flexor tendon repair.

Achieving satisfactory digital motion after suturing severed flexor tendons remains a challenge. Although a suture technique proposed by Savage is stronger in vitro than a true Kessler repair, the Savage technique has not been previously tested in vivo. We repaired 96 severed canine tendons using either of two modifications of the Kessler technique or the Savage technique. The tensile strength of these repairs were compared at 0, 1, 3, and 6 weeks after suturing. The Savage technique provided a significantly stronger repair than the "suture locking" method in vitro and at 1 and 3 weeks after repair. We found no significant differences between the tensile strengths of the Kessler-Tajima and suture-locking methods at any time.

Arthrodesis of the proximal interphalangeal joint of the finger: comparison of the use of the Herbert screw with other fixation methods.

We report a retrospective review of 224 proximal interphalangeal joint arthrodeses in the digits using Herbert screws (37), Kirschner wires (100), tension band wiring (69), plates (11), and other miscellaneous techniques (7) for fixation. Average time to clinical union was 7 weeks and time to radiographic union was 10 weeks. Nonunion occurred in 31 cases (24 digits). The primary nonunion rate was highest in psoriatic arthritis, intermediate in rheumatoid arthritis, lower in acute trauma and post-traumatic reconstruction, and nonexistent in osteoarthritis. The primary nonunion rate was highest using Kirschner wires, intermediate using tension band wires, and lowest using Herbert screws. All Kirschner wires, six tension band wires and one Herbert screw were removed after fusion. The Herbert screw provides secure fixation, is easy to insert, and affords a rapid and reliable arthrodesis at the proximal interphalangeal joint.

Results of zone I and zone II flexor tendon repairs in children.

In a combined study of three hand surgery practices, 78 patients younger than 16 years who had sustained flexor tendon lacerations in zone I or zone II of 95 digits were available for critical evaluation. The average postrepair follow-up period was 24 months (range, 3-144 months). Patient age was divided into three groups: 0-5 years, 6-10 years, and 11-15 years. Performance of all digits was assessed to determine the percentage return of normal digital function following repair. Data were analyzed to determine the effect of age, the effect of varying periods of postrepair immobilization, and the long-term changes in digital performance resulting from growth. All profundus repairs in zone I returned excellent function. Isolated profundus and combined profundus and superficialis repairs in zone II achieved comparable results when managed with an early passive motion program or following immobilization for 3 or 4 weeks. Immobilization for longer than 4 weeks resulted in an appreciable deterioration of function. Digital motion following zone II flexor digitorum profundus and superficialis injuries treated with less than 4 weeks of immobilization or early motion was not significantly different in the three age groups studied. Digits with associated digital nerve and/or palmar plate lacerations fared less favorably when compared with isolated tendon lacerations. In many digits, a modest improvement in digital motion was found when patients returned after several years of growth.

Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: long-term results.

Ninety-two fingers with rheumatoid swan-neck deformity were treated with dorsal capsulotomy and lateral band mobilization. An initial increase of 55 degrees of motion into flexion was noted, but this proximal interphalangeal motion deteriorated over time. Of 15 fingers followed at 3 and 12 months, there was a mean loss of 17 degrees of the early postoperative flexion. Nineteen fingers with rheumatoid boutonniere deformity were treated with central slip reconstruction. The results were unpredictable, with only modest improvement in the proximal interphalangeal extension, which deteriorated over time. The authors now recommend arthrodesis for most severe rheumatoid boutonniere deformities.

[Arthrodesis of the wrist. Indication, technique and functional consequences for the hand and wrist]. / Die Arthrodese des Handgelenks. Indikation, Technik und funktionelle Konsequenzen für Hand und Handgelenk.

Three studies conducted in our center demonstrated an improved technical success rate and elimination of preoperative pain in patients undergoing wrist fusions, with no significant difference in the ability to perform rapid movements requiring manual dexterity in the course of activities of daily living compared with patients who had undergone motion-preserving limited arthrodeses. The only absolute drawback of wrist fusion is that it obviously does not allow for any wrist motion at all. Limited intercarpal arthrodesis preserves some motion, but according to our results never leads to increased motion postoperatively. Several specific skills were found to present difficulty in patients who had undergone total wrist fusion. These included those requiring volar flexion in a limited space, where it would be difficult to have recourse to compensatory motion imparted by the shoulder and elbow, and those requiring forceful pronation and supination with simultaneous strong grasping. For patients involved in certain occupations requiring fine manual dexterity in tight spaces, wrist fusion might not be the most appropriate procedure. It is interesting that there appears to be a learning curve to the patient's ability to undertake specific activities postoperatively. A strong practice effect is present for the first 3-6 postoperative months, during which time a significant improvement in the patient's overall function is noted. Total wrist arthrodesis gives highly predictable results in the treatment of wrist pain and instability. The ability to perform normal activities of daily living and strenuous manual tasks was comparable to that after alternative motion-preserving procedures. We have not observed improved wrist motion after any wrist motion-preserving procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Strength and functional recovery following repair of flexor digitorum superficialis in zone 2.

A two-pronged study was designed to evaluate the strength in vitro and functional recovery in vivo of FDS repairs in zone 2. In part I, horizontal mattress or Tajima grasping repairs were performed on fresh-frozen cadaveric digits, using 3/0 or 4/0 braided nylon suture material. The Tajima repair was significantly stronger than the mattress suture, using either 3/0 (P = 0.0001) or 4/0 (P = 0.0027) suture material. The 3/0 Tajima repair appeared strong enough to permit gentle early active motion. Furthermore, the clinical portion of the study (part II) demonstrated restoration of FDS function following repair in relatively isolated injuries in 13 out of 15 digits (86.7%), with PIP flexion averaging 80 degrees and grip strength 89% of that in the uninjured hand.

Adhesions between muscle and bone after forearm fracture mimicking mild Volkmann's ischemic contracture.

Five cases of digital flexion contractures after healed forearm fractures were incorrectly diagnosed as mild Volkmann ischemic contractures. All failed to respond to conservative therapy and were considered significant enough to require surgical correction. At surgery, the involved muscle-tendon units were densely adherent to the bone and callus of the fracture site with no evidence of ischemic involvement of the muscle. Lysis of adhesions and lengthening of the contracted muscle corrected the deformities.