Wrist arthrodesis: an alternative technique.

An alternative form of fixation was used for arthrodesis of 10 wrists in 10 nonrheumatoid patients. Fusion took place in all patients at an average of 7 weeks. There were 5 complications in 10 wrists after an average follow-up of 4 years. All patients had pain relief after the procedure, and 9 patients were able to return to their previous occupation.

Ulnar styloid impaction syndrome.

A series of 8 patients each with an excessively long ulnar styloid that was impacting the triquetrum, causing chondromalacia, synovitis, and pain, is presented. Four patients developed symptoms as a result of an injury and 4 had no definable acute precipitating injury. The average age at the time of surgery was 34 years. There were 3 male and 5 female patients. The average follow-up period was 34 months. All patients were treated by open partial ulnar styloidectomy. Outcome was evaluated clinically and by means of patient questionnaire and radiographs. Pain decreased from a preoperative average score of 3.5 to a postoperative average score of 1.3, which equates to mild pain requiring no medication. All but 1 patient returned to their previous employment unrestricted. The average preoperative ulnar styloid length was 7.4 mm and the average ulnar styloid process index was 0.41, which is almost twice normal. There were no complications. It is likely that an excessively long ulnar styloid has important implications for the kinematics of the lunatotriquetral interval. Details of the diagnosis of this condition, including a new provocative test, and operative management are discussed.

Open vs endoscopic carpal tunnel release.

We examined a consecutive group of patients who had undergone either open (34 patients) or single portal endoscopic (12 patients) carpal tunnel release performed by one surgeon over a period of 3 years. Fifty-seven total procedures were performed. There were no operative complications. Retrospective evaluation was done by questionnaire. We were unable to demonstrate any statistically significant difference between the two groups in terms of return to work, return to activities of daily living, or on a symptom severity scale.

Regulation of proliferation and platelet-derived growth factor expression in palmar fibromatosis (Dupuytren contracture) by mechanical strain.

Palmar fibromatosis (Dupuytren contracture) causes fibrosis of specific palmar fascial bands. These bands are subjected to repetitive mechanical strain in situ. Primary cell cultures were derived from (a) palmar fibromatosis from eight patients, (b) uninvolved palmar fascia (Skoog's fibers) from four of these patients, and (c) normal palmar fascia from four additional patients. The cells were plated onto collagen-coated membranes either subjected to cyclic strain (25% maximal strain at 1 Hz) or without strain. Bromodeoxyuridine incorporation showed an increase in proliferation in all cultures subjected to strain. This increase was highest for palmar fibromatosis (10 to 40% nuclear incorporation, p = 0.02). Skoog's fibers and fascia from the normal individuals showed a trend (not significant) toward increase with strain (8 to 25%, p = 0.15 for Skoog's fibers, and 8 to 15%, p = 0.45 for normal fascia). Cyclic strain increased the expression of platelet-derived growth factor-A relative to glyceraldehyde-3-phosphate dehydrogenase in palmar fibromatosis (2.2 to 3.5, p = 0.05) and Skoog's fibers (0.8 to 2.0, p = 0.04). The expression of platelet-derived growth factor-B relative to glyceraldehyde-3-phosphate dehydrogenase was enhanced by cyclic strain only in the fibromatosis tissue (0.7 to 2.1, p = 0.04). The normal fascia did not express platelet-derived growth factor. Platelet-derived growth factor neutralizing antibody decreased bromodeoxyuridine incorporation in fibromatosis cultures subjected to cyclic strain to near levels for those grown in the absence of strain (38 to 16%, p = 0.05). Conditioned medium from fibromatosis cells grown under stain showed a trend toward increased proliferation in additional fibromatosis cultures compared with conditioned medium from fibromatosis cells grown without strain (9 to 15% nuclear incorporation, p = 0.20). The observed palmar fibromatosis contracture can be partially explained on the basis of the cell's response to cyclic strain, which may be mediated by platelet-derived growth factor.

External fixation and cancellous bone grafting for Kienböck's disease: a preliminary report.

Between 1985 and 1990, 17 patients with histologically proven Kienböck's disease (Lichtman stages I, II, and III) underwent a combination of cancellous bone grafting to the lunate and external fixation across the wrist. All 17 patients were available for review with a minimum follow-up of 2 years (average, 47 years). Based on pain, functional status, range of motion, and grip strength (Mayo wrist score), there were 6 excellent, 6 good, 2 fair, and 3 poor results (2 of whom required further surgery). An overall success rate of 71% (12 of 17) was achieved. Ten patients underwent postoperative magnetic resonance scanning, and in 5, some improvement in signal intensity was demonstrated. The combination of cancellous bone grafting and external fixation is an alternative treatment for Kienböck's disease.

Midcarpal arthrodesis.

This retrospective review of midcarpal arthrodesis was undertaken between July 1985 and March 1990. Fourteen patients were identified and 11 were available for follow-up evaluation. Mean follow-up time was 66 months (range, 48-102 months). Four patients eventually underwent total wrist arthrodesis due to continued pain. Seven patients improved and each returned to work between 3 and 4 months after surgery. Wrist motion was 50% and grip strength 65% of the normal side. Midcarpal arthrodesis has a predictable fusion rate; however, it does not reliably relieve pain.

The pronator quadratus interposition transfer: an adjunct to resection arthroplasty of the distal radioulnar joint.

Ulnar head resection for treatment of painful traumatic and arthritic conditions of the distal radioulnar joint has been performed for over 100 years. Although this is a time-honored procedure, several negative sequelae of the operation have been described. Most of these problems have been due to the instability of the ulna remnant with respect to surrounding structures, including the radius and extensor tendons. This report describes an operative technique to prevent and treat this problem. The pronator quadratus origin is transferred to the dorsum of the ulna, placing the muscle belly between the radius and the ulna remnant. Theoretically, this may provide a soft tissue cushion to prevent ulnoradial impingement. We have been performing this operation since 1985 and report here the results on 16 wrists in 15 patients who underwent surgery between 1985 and 1989. Patients included in this study had pain in the distal radioulnar joint due to osteoarthritis, post-traumatic arthritis, or incongruity. No patients with rheumatoid or other autoimmune arthritis were included. The average follow-up period was 8 years, with a range of 5-9 years. Two groups of patients were studied, including seven who had failure of prior ulna head resection and eight who underwent this procedure (one on both wrists) concomitantly with ulnar head resection.

Carpal instability.

A great deal of progress has been made in recent years with respect to understanding the normal and pathologic anatomy of the wrist. Nonetheless, our knowledge is incomplete, so there still is room for diversity of opinion regarding the diagnosis and treatment of most of the presently recognized wrist instabilities. A careful history and physical examination combined with a critical review of the standard radiographs, supplemented by additional studies as indicated, allow the astute clinician to identify specific patterns of instability and to formulate an effective treatment program for the patient.

Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid.

Twenty-five patients had Russe anterior corticocancellous bone-grafting between 1973 and 1984 for twenty-six symptomatic established non-unions of the scaphoid. The mean duration of follow-up was eleven years (range, seven to eighteen years). Twenty-one (81 per cent) of the twenty-six scaphoid bones united. We developed two rating scales to evaluate the results of the operation. One scale, based on objective findings, included the radiographic appearance of the wrist, the range of motion, and strength; the other scale, based on subjective findings, comprised function, pain, perception of a decrease in performance because of limitation of motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had a malunion of the scaphoid in which the lateral intrascaphoid angle was more than 45 degrees convex dorsally between the proximal and distal poles (a so-called flexion or humpback deformity, which results in extension of the proximal fragment of the scaphoid at the radiocarpal joint) with the results in patients who had no such deformity. The lateral intrascaphoid angle was more than 45 degrees in thirteen (50 per cent) of the twenty-six wrists. Although the difference in the objective results between the wrists that had a malunion and those that did not have a malunion was highly significant (p = 0.001), there was no significant difference in the subjective results between the two groups, including satisfaction of the patient (p = 0.39). Twenty-three patients (92 per cent) returned to full-time employment and twenty-two (88 per cent), to sports activities. Twenty-three patients (92 per cent) reported that they had pronounced relief of pain and that the procedure had improved their quality of life. The presence of this deformity of the scaphoid after bone-grafting for a symptomatic non-union was not predictive of a poor long-term subjective outcome.

Nonrheumatoid closed rupture of extensor carpi ulnaris tendon.

Closed rupture of the extensor carpi ulnaris tendon in a patient who does not have rheumatoid arthritis has not been previously reported to our knowledge. This condition should be considered in the differential diagnosis of ulnar-sided wrist pain. We report two patients with favorable response to surgical reconstruction after failure of nonoperative management.

Metacarpal fractures and dislocations.

Metacarpal fractures are common injuries. Most can be treated successfully by closed reduction and cast or splint immobilization. Unstable fractures, however, require internal fixation. Many such techniques are discussed. Metacarpal dislocations are more difficult to diagnose and treat than are metacarpal fractures. Careful attention to detail will help ensure a successful result.

Attempted scapholunate arthrodesis for chronic scapholunate dissociation.

We report a retrospective review of seven patients with chronic scapholunate dissociation treated with attempted scapholunate arthrodesis. All procedures were done between 1978 to 1983 by one surgeon. Seven patients with follow-up of nine months or greater were available for review. Follow-up for the four patients with successful operations averaged seventy-seven months. Average age was 34 years (range from 19 to 46). Only one patient demonstrated radiographic fusion. Of the remaining six patients, three had no further wrist pain. The other three operations were total failures requiring other procedures for pain relief. For all patients, flexion-extension are decreased an average of 4 degrees. Grip strength averaged 88% of the unaffected side. Lateral scapholunate angle improved from an average preoperative angle of 70 degrees to a postoperative angle of 59 degrees. We conclude that this procedure is not a predictable method to treat scapholunate dissociation.

Results of extensor carpi ulnaris tenodesis in the rheumatoid wrist undergoing a distal ulnar excision.

Distal ulna resections that are done in patients with rheumatoid arthritis to alleviate pain, correct alignment, and prevent tendon rupture may contribute to distal ulnar instability. A distally based slip of the extensor carpi ulnaris tendon has been used to both stabilize the distal ulnar remnant and to prevent recurrent deformity in 26 rheumatoid wrists, with an average follow-up of 3.5 years. In all postoperative cases, the distal ulna was no longer prominent and the wrist was well aligned. The distal ulna was stabilized in 96% of the patients. Subjectively, pain was relieved in 85% and grip strength improved in 77%.

The distal radioulnar joint in rheumatoid arthritis.

Rheumatoid arthritis commonly affects the distal radioulnar joint (DRUJ). This can result in pain, instability, or tendon rupture. The goals of surgical reconstruction of the DRUJ are to relieve pain, stabilize the joint, and prevent tendon rupture. We review many of the previously described procedures and report our experience with distal ulna excision and soft tissue reconstruction with a distally based slip of extensor carpi ulnaris tendon.

Variations of the flexor digitorum superficialis of the small finger.

Normal functional variations of the flexor digitorum superficialis were clinically determined by use of the standard and modified superficialis flexion tests in 50 normal subjects. Forty hands of 20 cadavers were dissected to correlate the anatomic variations with the clinical findings. A flexor digitorum superficialis-independent pattern was found 58% of the time. A flexor digitorum superficialis-common pattern was found 21% of the time. A flexor digitorum superficialis-absent pattern was found 21% of the time. The right and left hands were asymmetric 26% of the time. All cadaver hands had a flexor digitorum superficialis tendon present in the palm and finger. The variability in flexor digitorum superficialis function may be explained by interconnections between the flexor digitorum superficialis of the small finger and either the flexor digitorum superficialis of the ring finger or the flexor digitorum profundus of the small finger.

Relative motion of selected carpal bones: a kinematic analysis of the normal wrist.

The relative motion of selected carpal bones and the radius was studied using five cadaver specimens labeled with metal markers to precisely quantitate their motions. Data was obtained by means of a combination of orthoradiography, sonic digitization, and computer analysis. We conclude that the wrist functions as two carpal rows with the distal row bones relatively tightly bound to one another and the proximal row bones less so but still moving together. Therefore, we theorize that the proximal row functions as a variable geometry intercalated segment between the distal row and the radius-triangular fibrocartilage.

Coverage of a carpal tunnel wound dehiscence with the abductor digiti minimi muscle flap.

A 41-year-old man who was taking 60 mg of prednisone a day for dermatomyositis developed a wound dehiscence following a carpal tunnel release and flexor tenosynovectomy. Coverage of the exposed carpal contents was provided by using the abductor digiti minimi as a local transposition flap.

Wrist arthritis associated with scaphoid nonunion.

Patients with old scaphoid nonunion have a high risk of developing wrist arthritis. Although some patients remain asymptomatic, some will have pain sufficient to seek treatment. There are several treatment options available. The authors prefer wrist arthrodesis for most of these patients.