A team approach to reduce disability in work-related disorders.

Work-related disorders require a multidisciplinary approach. One must understand musculoskeletal disorders, job issues, and psychosocial issues that prolong disability. This introductory article presents an overview of the approaches to management that will be detailed in the articles that follow.

Occupational soft-tissue and tendon disorders.

Reports of work-related musculoskeletal disorders have increased. The cause of the problem has yet to be determined. Thus far, only cross-sectional case and controlled studies exist. It is important for the physician to develop a thought process to separate patients with subjective complaints and real objective findings from those with unreasonable subjective complaints and minimal or no findings.

Management of work-related upper-extremity nerve entrapments.

Peripheral nerve symptoms are common in the worker. Great care must be given to obtain an accurate diagnosis. Diagnostic labels should not be used unless one is sure of the diagnosis. A detailed evaluation of the worker, job, and medical and psychosocial conditions must be performed. Nonoperative treatment is primary. Understanding at-risk patients and managing them carefully can decrease disability and improve results following treatment. The results from surgery are less successful in work-related disorders and disability is often prolonged. Surgery should only be performed for clear diagnoses and clear indications after adequate nonoperative treatment, with careful consideration of the job to which the worker will return.

Intrinsic muscle flaps: the treatment of painful neuromas in continuity.

Treatment of the pain that is caused by neuroma in continuity in a digital nerve on the palmar surface of the hand is a challenging problem. Eight digital nerves were covered with intrinsic muscle flaps after neurolysis to obtain relief of symptoms in eight patients. Four of the cases involved intrinsic muscles for digital nerves in the thumb. Four patients had digital nerves in the palm covered by lumbrical muscle flaps, two of which were distally based. All patients had significant relief of their symptoms. This report describes the techniques used and their application.

Camitz palmaris longus abductorplasty for severe thenar atrophy secondary to carpal tunnel syndrome.

This is a retrospective review of 29 patients (33 hands) who underwent a palmaris longus transfer because of severe thenar atrophy secondary to median nerve entrapment at the wrist. The mean follow-up was 17 months. Ninety-four percent of our patients were satisfied because their thumb function improved. Twenty-six of the patients had the transfer at the time of initial release of the carpal tunnel, and three patients had the transfer when the carpal tunnel was released a second time. The transfer helps with thumb palmar abduction, and the palmaris longus is an expendable muscle for transfer.

Factors that determine reexploration treatment of carpal tunnel syndrome.

Eighteen patients (20 hands) underwent reexploration of the carpal tunnel after a primary carpal tunnel release. The patients complained of unrelieved symptoms after their initial surgical procedures. We recommend reexploration for patients with unrelieved carpal tunnel syndrome if they have a positive Phalen's test, have symptoms that cause nocturnal wakening or are exacerbated by activities, or have a short or transverse initial incision. If the incision is adequate and these symptoms are not present, we believe that reexploration will not result in a satisfactory outcome.

Reconstruction of the rheumatoid thumb.

Most rheumatoid patients will present with one or more thumb deformities at some stage of their clinical history. The goal of treatment is restoration and maintenance of stable and painless motion. Treatment is based on the type and stage of the deformity. The boutonniere thumb is the most common deformity. Metacarpophalangeal arthrodesis is preferred for isolated metacarpophalangeal involvement. For advanced cases in a low-demand patient, metacarpophalangeal arthroplasty with interphalangeal arthrodesis is performed. In the higher demand hand with an uninvolved carpometacarpal joint, arthrodesis of both metacarpophalangeal and interphalangeal joints may be considered. The less common swan neck is approached by treating the carpometacarpal joint with a hemiarthroplasty or a total resection with capsulodesis or arthrodesis of the metacarpophalangeal joint. Adduction contracture is treated by Z-plasty of the skin of the first web space and release of the adductor aponeurosis. Gamekeeper's deformity is treated with reconstruction of the ulnar collateral ligament. Arthrodesis is recommended for those patients with articular erosion of the metacarpophalangeal joint. Flexor pollicis longus and extensor pollicis longus tendon ruptures are common in rheumatoid patients. Extensor pollicis longus ruptures are usually treated with EIP transfer or observation. Flexor pollicis longus ruptures are more disabling and usually require a tendon transfer, tendon graft, or an interphalangeal joint fusion in patients with radiographic destruction of that joint.

Silicone rubber arthroplasty of the wrist.

The wrist is often referred to as the keystone of the hand. It is often affected in rheumatoid arthritis. Salvage procedures for patients with rheumatoid arthritis involving the wrist include silicone wrist arthroplasty, total joint arthroplasty, and wrist arthrodesis. In 1967, Swanson developed a double-stem, flexible-hinge implant for the radial carpal joint. In 1982, metal titanium bone liners (grommets) were added to help decrease the incidence of fractures. The authors feel that the gold standard is still wrist arthrodesis. However, they would use a flexible wrist arthroplasty in a patient who has bilateral wrist involvement with marked digital deformity and/or proximal interphalangeal stiffness. This is especially true in low-demand patients who have good alignment, good bone stock, and the associated proximal and distal disease. If these criteria are met and meticulous technique used, successful reconstruction of the wrist with a flexible wrist silicone implant can be performed in the patient with rheumatoid arthritis.

Nonoperative treatment of anterior interosseous nerve paralysis.

Although the current recommendation for the treatment of spontaneous anterior interosseous nerve paralysis is surgical decompression, there has been recent evidence in the neurologic literature that these lesions are examples of a neuritis. We followed 10 cases of spontaneous partial anterior interosseous nerve paralysis. All patients were seen initially with a typical history of pain. Seven had signs of other nerve involvement either on physical examination or electromyogram analysis. Eight patients treated by observation had signs of recovery in 6 months and full recovery within 1 year. Surgical decompression did not affect recovery time in the other patients. Our findings suggest that anterior interosseous nerve paralysis is a form of neuritis and can safely be treated without operation. These patients will achieve complete recovery.

Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow.

Decompression of the ulnar nerve at the elbow with medial epicondylectomy was done in 43 patients and reviewed with an average follow-up of 2.3 years. Eight were graded as excellent, 23 as good, 9 as fair, and 3 as poor results. A special emphasis was placed on analysis of the potential disadvantages of medial epicondylectomy including bone tenderness at the osteotomy site, vulnerability of the ulnar nerve, ulnar collateral ligament instability, and weakness from disruption of the flexor pronator origin. Clinical assessment of strength including quantitative measurement of pinch strength, grip strength and endurance, and testing of forearm muscles did not show these potential disadvantages to be significant problems.

Treatment considerations in the complicated rheumatoid hand.

The rheumatoid patient with complex involvement or multiple deformities of the hand and wrist can be a challenge to the hand surgeon. A systematic and orderly approach is used to formulate and execute a treatment plan that is realistic and that can result in modest, but significant improvement in overall hand function. The evaluation and treatment philosophy which is described can help turn a complicated and seemingly overwhelming situation into smaller components which can be treated in one or more surgical stages.

Flexor tendon ruptures in patients with rheumatoid arthritis.

One hundred fifteen flexor tendon ruptures were reviewed in 43 hands with rheumatoid arthritis, one hand with psoriatic arthritis, and one hand with lupus erythematosis. Ninety-one tendons were ruptured at the wrist, four ruptures occurred at the palm, and 20 ruptures occurred within the digits. At the wrist level, 61 ruptures were caused by attrition on a bone spur and 30 were caused by direct invasion of the tendon by tenosynovium. All ruptures distal to the wrist were caused by invasion of the tendon by tenosynovium. Patients whose ruptures were caused by attrition regained better motion than those whose ruptures were caused by invasion by tenosynovitis; however, motion overall was poor. Patients with isolated ruptures in the palm or at the wrist had the best functional results. Those patients with multiple ruptures within the carpal canal had a worse prognosis. Ruptures of both tendons within the fibro-osseous canal had the worst prognosis. The severity of the patient's disease and the degree of articular involvement had a great effect on the outcome of surgery. Prevention of tendon ruptures by early tenosynovectomy and removal of bone spurs should be the cornerstone of treatment.

Bowstringing as a complication of trigger finger release.

Bowstringing is a rare complication of trigger finger release caused by excessive loss of the proximal pulleys. As the flexor tendon moves away from the center of rotation of the metacarpophalangeal joint, the flexion moment arm is increased. Thus the flexors gain an increased mechanical advantage over the extensors resulting in limited digital extension. We describe a case of severe bowstringing progressing over 9 years resulting in pain, altered digital function, and loss of full extension.

Failure of silicone rubber wrist arthroplasty in rheumatoid arthritis.

Of 71 silicone rubber wrist arthroplasties performed between 1976 and 1983, 20% were found to have fractured, and an additional 5% required revision for deformity and pain. In most cases, no specific cause for the failure could be identified. However, excessive wrist motion, overuse, and inadequate surgical technique appear to be contributory. Prosthetic fracture is associated with increasing wrist pain, instability, and deformity with decreasing strength and function. Twelve of 14 fractured prostheses required revision. Eleven of these were revised with another silicone rubber implant, and two of these have refractured. Based on this review, we have narrowed our indications for silicone rubber wrist arthroplasty and now give greater consideration to alternative methods of treatment.

Tenosynovial osteochondroma of the hand. A case report and brief review.

A 61-year-old man presented with a slowly growing, painless mass over the dorsum of his right hand. Roentgenography, computed tomography, and a radionuclide bone scan revealed a soft-tissue mass with mineralization but no bone or joint involvement. Routine laboratory tests and a chest roentgenogram were negative. A biopsy was inconclusive. The mass was removed en bloc and was diagnosed as synovial osteochondroma arising from the extensor tendon sheaths. The patient has been symptom-free 16 months postoperation. The literature indicates that these tumors occur almost exclusively in the hands or feet and are thought to develop by metaplasia from the mesenchymal cells of the synovial membrane; mineralization and ossification of the tumor are secondary. The actively growing tumor is often cellular and may show atypical cytologic features. Such microscopic characteristics should not be interpreted as evidence of a low-grade chondrosarcoma. A review of the literature failed to disclose a case with malignant transformation, although several lesions had recurred, some more than once. For this reason, complete removal of the involved synovia is of great importance.

Fractures of the hook of the hamate--a failure of clinical diagnosis.

Two cases of a fracture of the hook of the hamate are described in which the diagnosis was clinically missed even though a fracture of the hook was considered. In one patient, the clinical diagnosis was thought to be ulnar wrist instability, and in the other, a pisiotriquetral injury. In one case, the diagnosis was confirmed only by a computerized tomography scan even though lateral tomograms were negative.

Bilateral partial ruptures of the flexor carpi radialis tendon secondary to trapezial arthritis.

This is a report of bilateral partial ruptures of the flexor carpi radialis tendons associated with trapezial osteoarthritis. Splinting for 4 weeks was curative. One of the tendons was exposed 4 months after rupture in conjunction with carpal tunnel release and the abnormal healed tendon was revealed.