The pattern of muscle involvement in poliomyelitis of the upper limb

The pattern of muscle paralysis and paresis in the upper limb has been studied in 31 children with poliomyelitis. The incidence of involvement of the upper limb alone is the same as of the upper and lower limbs together, and of the spine and upper limb. The left arm was more commonly affected than the right. The muscle most frequently paralysed was the deltoid. When complete paralysis of the whole deltoid occurred and was associated with paralysis of the rotator cuff muscles, the shoulder often subluxed downwards. The next most commonly affected muscles were the elbow flexors and extensors. In the hand the opponens pollicis was most often involved. As far as the spinal segments are concerned, C5 involvement was usually associated with paralysis and C7 with paresis.

Tuberculosis of the upper limb joints

Seventy-four cases of tuberculosis of the upper limb joints (sterno-clavicular 1; shoulder 12; elbow 42; wrist 10 and fingers 9), treated by two of the authors, were reviewed. Eighty-seven percent presented at an advanced stage of destruction. The diagnosis was proved in 71 our of 74 cases. In most, the treatment was 6-12 months of chemotherapy, plaster immobilization (in order to prevent or correct deformity) and functional rehabilitation whenever possible. The sterno-clavicular and finger joints were not immobilized. Response to chemotherapy was favourable in 66 of the patients followed up. One relapse occurred at the 18th month. The affected shoulder joints healed with loss of movement, but were not painful. At the elbow, ten patients developed spontaneous bony fusion in the right-angle position, 27 had a useful range of motion and 19 had more than 70 degrees of flexion-extension movement. One patient had an arthrodesis. At the wrist, two patients healed with painful stiffness and an arthrodesis was performed. All the finger lesions healed with painless stiffness which did not interfere much with function because rehabilitation had been started early. The authors believe that conservative management usually gives better results than arthrodesis or excision of the joint.

Indium-111 leukocyte imaging in patients with rheumatoid arthritis

This study evaluates the usefulness of labeled leukocyte imaging in patients with rheumatoid arthritis. In 33 patients, the incidence of pain and swelling in 66 wrist joints and 66 knee joints was compared with the accumulation of [111In]leukocytes. No accumulation of [111In]leukocytes was seen in any of the patients' wrists (0/12) or knee joints (0/14) when both pain and swelling were absent. In contrast, 93% (25/27) of wrist joints and 80% (24/30) of knee joints with both pain and swelling were positive by [111In]leukocyte scintigraphy. There was little correlation between the stage of the disease, as determined by radiography, and [111In]leukocyte accumulation. This study suggests that [111In]leukocyte imaging may be a reliable procedure for monitoring the activity of rheumatoid arthritis, especially for confirming the lack of an ongoing inflammatory response.

The in vivo kinematics of the rheumatoid wrist

The objectives of this study were to describe the three-dimensional in vivo kinematic behavior of wrists affected by rheumatoid arthritis, to correlate kinematic parameters and two radiographic indices of carpal disease, and to describe the in vivo kinematic behavior of the Swanson Silastic wrist implant. Fifteen normal wrists, 17 rheumatoid wrists, and 7 wrists with Silastic wrist implants were tested using a three-dimensional sonic digitizing system. The motion of the hand segment relative to the forearm segment, corresponding to the positions exhibited during flexion-extension motion (FEM) and radial-ulnar deviation (RUD), was described using the equivalent screw displacement (ESD) concept. The mean magnitudes of ESD rotation for both FEM and RUD were statistically different (p less than 0.05) among the normal, rheumatoid, and implant groups. The remaining ESD parameters (i.e., mean values for the translation, the direction angles of the ESD axis, and the intercepts of this axis with the planes of motion), the minimum separation between the FEM and RUD axes, and the coordinates of the midpoint of this separation were not statistically different (p greater than 0.05) among the normal, rheumatoid, and implant groups. The two radiographic indices (carpal collapse and carpal translation) did not correlate with the magnitude of rotation or with any other ESD parameter.

ECRL-strip platy for metacarpal base fixation after excision of the trapezium

Excision of the trapezium is always followed by instability and proximal migration of the first metacarpal base. In the present report, a modification of a previously suggested technique of metacarpal fixation is presented. The base is trapped between the APL- and FCR-tendons by means of a strip from the ECRL-tendon. This technique was applied in 44 thumbs with trapezial arthrosis. Stability and mobility were restored in all thumbs and the results as to strength and freedom from pain were successful in 80%. The suggested procedure is simple both technically and in regard to post-operative care and is particularly suitable in older patients.

A biomechanical comparison of the methods for treating Kienböck's disease

Reduction of lunate compression is thought to promote revascularization of the lunate in patients with Kienböck's disease. The decompressing abilities of ulnar lengthening, radial shortening, capitate-hamate fusion, and scaphoid-trapezium-trapezoid (STT) fusion were examined in axially loaded, whole arm specimens. Lunate strain was monitored by electronic strain gauges and found to be proportional to the axial load borne by the bone. The STT fusions and the procedures to alter relative radial and ulnar length were successful in relieving lunate loading throughout a functional range of wrist motion and forearm rotation, but the capitate-hamate fusion was ineffective. Only the STT fusion resulted in a significant decrease in wrist range of motion. Incremental ulnar lengthening and radial shortening revealed that approximately 2 mm of length change maximizes lunate decompression without greatly increasing the risk of disorders of the distal radioulnar joint and ulnocarpal impingement.

Scaphoid implant resection arthroplasty. Long-term results

A silicone scaphoid implant was developed in 1967 to help improve the results of simple resection arthroplasty in the treatment of arthritic changes associated with advanced scaphoid disease. Patients who had scaphoid implant surgery since 1967 were studied. Preoperative and postoperative roentgenograms, charts, surgical pathology, and clinical evaluations were reviewed. A total of 55 cases of scaphoid implant arthroplasty were evaluated. A classification system was developed based on progressive severity, and treatment recommendations were developed for each stage of disease progression. Cystic and degenerative changes in contiguous carpal bones were evaluated. No evidence of cystic change could be found in 37 wrists, minimal changes were found in 9, moderate changes in 5, and severe changes in 4. There were no implant infections or fractures. Implant rotation occurred in two cases. Functional use of the hand with decreased pain was observed. It is important to detect and treat carpal instability, which may be associated with scaphoid disease. Cystic formation can be minimized by avoiding oversized implants, treating the associated carpal instability, bone-grafting preexisting cysts, and avoiding Kirschner wire fixation. By following treatment protocols as established in the classification system, the scaphoid implant can be successfully used in the management of scaphoid pathology.

A critical analysis of alignment factors influencing functional results following trispherical total wrist arthroplasty

In a study of the impact of selected patient factors and alignment variables on functional results of total wrist arthroplasty, functional score and range of motion were found to be improved and incidence of component shift and progressive radiolucent lines decreased by proper positioning of the implant center of rotation and restoration of carpal height. Angulation of the implant stems was secondary in importance to the other positioning variables with respect to overall function and durability. A neutral alignment range for this implant arthroplasty was proposed. Within this neutral range, functional score averaged 94 points and range of motion averaged 68 degrees. There were no reoperations, component shifting, or progressive radiolucent lines, and all wrists rated an excellent score.

Radiolunate arthrodesis

The procedure of radiolunate arthrodesis was suggested by spontaneous radiolunate arthrodesis that resulted in painless, satisfactory function. Ulnar translation down the inclined slope of the radius is accelerated by dorsal dislocation of the ulnar head, ulna minus variance, and triangular fibrocartilage resorption and may be an inducement to increased ulnar deviation of the fingers as well as disintegration of the proximal carpal row. Twenty-two radiolunate arthrodeses were performed, 16 by a corticocancellous slotted graft and six by a modified Lauenstein procedure in 17 rheumatoid and five traumatic cases. Nineteen wrists were available for follow-up at an average of 28 months. Average range of motion was 25 degrees of extension, 30 degrees of flexion, 5 degrees of radial deviation, and 15 degrees of ulnar deviation. Subjective evaluation was good in 14 wrist, fair in three, and poor in two. Relief of pain was generally satisfactory, and preoperative grip strength was slightly improved. Progressive degeneration of the midcarpal joint tends to be minimal. If further spontaneous arthrodesis occurs, the wrist remains in satisfactory position. Carpal ulnar translation, midcarpal angulation, and radial angulation are corrected. Loss of carpal height is partially corrected in most instances.

The rheumatoid wrist after resection of the distal ulna

Thirty-three wrists in 25 patients with rheumatoid arthritis were followed for an average of 3.8 years after resection of the distal ulna. These patients, including those who had adjunctive implantation of a silicone rubber cap, manifested considerable amounts of carpal collapse, carpal translocation, rotational change of the wrist, and radial shift of the ulna. The progression of these complications was unpredictable. Four patients required revision. Three of these four patients had no articular contact between the lunate and radius on their preoperative x-ray film. Excision of less than 20 mm of the distal ulna is an acceptable range of resection. In 15% of the wrists, an osseous carpal stabilizer was seen on the preoperative x-ray film as a reliable radiographic indicator of radiocarpal stability. Another 12% of patients developed a bony carpal stabilizer during the postoperative period.

Rheumatoid wrist reconstruction utilizing a fibrous nonunion and radiocarpal arthrodesis

Rheumatoid arthritic involvement of the wrist severely limits the functional status of the upper extremity. Total wrist arthrodesis, while providing pain relief and reestablishing support, compromises the functional capacity of the hand because of lack of wrist motion. Wrist arthroplasties allow motion, but have not found wide acceptance because of instability and the recurrence of deformity. A technique for establishing an intentional fibrous nonunion between the carpus and the radius was devised 17 years ago. This fibrous hinge gives wrist stability with or without radiocarpal wrist arthrodesis while allowing painless motion at the fibrous radiocarpal hinge and at the less severely involved midcarpal joint. Twenty-three patients have been followed for more than 7 years. All patients whose wrists achieved nonunion had no pain. Twelve of the 19 wrists in which radiocarpal arthrodesis occurred had no pain, and seven had mild pain that did not limit use.

External fixators for wrist fractures: a biomechanical and clinical study

The rigidity of four external fixators for the wrist was determined by using the Instron universal testing instrument. Using the equivalent stiffness index, the small A.O. was 7.6, the mini Hoffman was 3.7, Roger Anderson was 3.5, and Ace Colles' was 4.3. Thus, the small A.O. was about twice as rigid overall as the other three external fixators. Twenty-two patients with unstable distal radius fractures were treated with the mini Hoffman external fixator over a 3-year period; and follow-up data were obtained. The average final angle of the distal radial articular surface on the anteroposterior x-ray film was 17.5 degrees. The final angle of the distal radial articular surface on the lateral x-ray film was 2 degrees dorsal. The final height of the distal radial styloid averaged 8 mm. The final range of motion of the wrist compared with the opposite normal hand was extension 77%, flexion 77%, ulnar deviation 82%, radial deviation 73%, pronation 84%, supination 78%, and grip strength 72%. Complications included three cases of broken pins, one of a pin loosening with migration, one case of tendon rupture, and one of intrinsic contracture. From our experience, the Hoffman external fixator gave adequate clinical and functional results and can be used safely in the small to average size patient. A more rigid external fixator should be used for larger and more active patients. External fixation is an excellent way to treat unstable distal radial fractures.

Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb

Arthrosis of the trapeziometacarpal joint of the thumb is a predictable sequelae of ligament laxity. A new technique of tendon interposition arthroplasty with ligament reconstruction using the flexor carpi radialis tendon for a painful arthritic trapeziometacarpal joint of the thumb is described. Twenty-one patients had 25 operative procedures; 14 were women and seven were men. All of the patients presented with intractable pain, crepitus, and varying degrees of laxity of the basal joint. Pinch strength was diminished. Follow-up averaged 37 1/2 months. After surgery, 91.7% of patients had good to excellent results, and 56% were completely pain free. Range of motion and grip and pinch strengths were equal on the operated and unoperated sides.

Swanson silastic wrist arthroplasty. A retrospective study of fifteen cases

A retrospective study of fifteen Swanson silastic wrist replacements for rheumatoid arthritis (fourteen cases) and osteoarthritis (one case), with a mean follow up period of 28.3 months showed an increase in function in fourteen cases and no change in one case. An increase in range of movement was present in six cases, with no change in seven. Pain was improved in fourteen cases and unchanged in one case. Grip strength was improved or unchanged in twelve cases. There were two cases of prosthesis fracture.

Arthrotomography of the wrist: an experimental and preliminary clinical study

Experimental arthrotomography including posteroanterior and lateral projections was completed in 18 fresh-frozen wrists from cadavers with an average age of 65 years at death. Arthrotomographic findings were correlated with anatomic dissections. Three types of defects of the triangular fibrocartilage complex were clearly defined in 38% of wrists. Chondromalacia was present in 24% of wrists, in all cases on the ulnar half of the proximal surface of the lunate bone. The palmar radiocarpal ligaments (radiocapitate and radiotriquetral) were visible in all specimens. Experimental arthrotomography appears to be useful in defining the nature and location of soft tissue pathology in clinical practice. Clinical arthrotomography was performed in 16 patients, all with a syndrome of chronic wrist pain. Pathologic findings were observed in 11 wrists, including four perforations of the triangular fibrocartilage complex, two cases of chondromalacia of the lunate, one tear in each of the scapholunate and lunotriquetral ligaments, three occult palmar ganglia, and one recurrent dorsal ganglion. The soft tissues in five wrists were normal. The preliminary clinical experience with wrist arthrotomography has yielded results that have significantly affected the care of patients, including the planning of operative treatment and patient counseling.

Silastic sheet interposition arthroplasty for the painful rheumatoid wrist: a long-term review

Silastic sheet interposition arthroplasty was performed in 20 patients with persistently painful but stable wrists. Synovial recurrence with progression of symptoms was seen in one patient. Quantitative analysis of pain demonstrated an 87% improvement in their perception of pain in the remaining 19 patients, with an average follow-up of 8.5 years. The postoperative range of motion was 58 degrees Total Active range of Motion (TAM) (range 27 degrees - 97 degrees). Nine patients showed later ulnar translocation of the carpus, and 10 patients had continuing carpal collapse. There was no relation between these changes and the degree of pain relief at the radio-carpal joint. Those patients operated on within 18 months of the onset of symptoms showed a significantly greater post-operative range of motion (68 degrees) compared to those whose symptoms had persisted from 2 to 4 years (48 degrees).

Dynamic splint to reduce the passive component of hypertonicity

A study was conducted to test the effectiveness of a newly designed dynamic splint in reducing the passive component of hypertonus. Splinting and P-ROM exercise were compared among eight elderly subjects matched by age and sex with hemiparesis, one year after cerebrovascular accident. Spring-weighted scale measurements of the passive force of the wrist from 0 degrees flexion/extension towards flexion were used as dependent measures. Measurements were taken three days per week for six weeks. Data demonstrated that a significant reduction of hypertonus occurred among the splinted group but not the P-ROM group. A further comparison with previously published data on the effects of static splinting demonstrated that dynamic splinting led to a greater reduction of hypertonus than static splinting and P-ROM exercises.

[Thermographic diagnosis of arthritis in peripheral joints]

The measurement of absolute temperatures on the surface of the human body using quantitative thermography allows this technique to be used in rheumatology, for the diagnosis and monitoring the course of inflammatory diseases of the locomotor system. The patient is exposed to a room temperature of 18 degrees C and the skin temperature measured over the joint for a defined area (region of interest). Inflamed joints show distinctly higher absolute temperatures than normal ones within the observation time of 40 minutes. Moreover, the skin over healthy joints cools faster and to a greater extent than skin over inflamed joints, whose temperatures remain the same or even rise minimally in more acute cases. Using two measurements, the determination of the absolute temperatures (static thermography), and the changes in these temperatures within a definite time interval (dynamic thermography) it is thus possible to establish a diagnosis of arthritis in the regions of the peripheral joints with the help of standardised nomograms with an accuracy of more than 90%, and to follow the course of the disease more exactly.

Total trapeziometacarpal arthroplasty. Report on seventeen cases of de generative arthritis of the trapeziometacarpal joint

The authors have studied the results of 17 total trapeziometacarpal arthroplasties, performed in 15 patents between 1973 and 1983. The indications were essentially arthritis of the trapeziometacarpal joint either isolated or associated with peritrapezial lesions. The mean follow-up period was 3 years, the extremes ranged from 1 to 10 years. Results were judged as good in 13 cases, average in one case with 3 failures. Good results allow to recuperate complete mobility with adequate strength and stability.. The key point of this study was that first, cemented total arthroplasty does not represent a surgical escalade, a repeat operation is always possible in case of failure, and second, the concept of peritrapezial arthritis, and especially Crosby's stage 1 or stage 2 scaphotrapezial arthritis, is not a contraindication for total trapeziometacarpal arthroplasty. The best indications seems to be intense Dell's stage 3 or stage 4 trapeziometacarpal arthritis either isolated or associated with moderated peritrapezial arthritis. Two elements must be particularly studied before thinking about total trapeziometacarpal arthroplasty: the size, the consistancy and the configuration of trapezium; the degree of eventually associated scaphotrapezial arthritis.

Comparison of early passive motion and immobilization after flexor tendon repairs

Thirty-one flexor tendon repairs in 30 patients managed by early passive motion were retrospectively compared with 31 flexor tendon repairs in 30 patients managed by 3 weeks of postoperative immobilization. Repairs were performed by several surgeons, including plastic surgical residents. There were no statistically significant differences between the two groups comparing age, zone of injury, number of tendons repaired, nature of injury, or associated injuries. No statistically significant difference was found between the two groups when total active and total passive range of motion were compared for repairs in zone I, zone II, zones III and IV, and all zones combined. In the early passive motion group in zone II, there were 12 percent excellent results, 15 percent good results, 23 percent fair results, and 50 percent poor results. In the immobilization group, there were 18 percent excellent results, 8 percent good results, 23 percent fair results, and 53 percent poor results. There was no significant difference between the two groups (p less than 0.05).

Kinematic features of wheelchair propulsion

Three male paraplegics volunteered to push their wheelchairs on a motor driven treadmill, for a total of 80 min each, at a work rate of 60-65% of their VO2 maximum, determined on an earlier test session. At 20 min intervals 16 mm high-speed film of the subjects was taken for three consecutive push cycles. The digitized film was used to compute the angular kinematics of the shoulder and elbow joints, the variations in the position of the trunk (as measured by a marker on the neck) and hand relative to the axle of the rear wheel. There were no intrasubject variations over the 80 min testing period for any of the recorded variables. This was interpreted as implying that at that work rate, fatigue was not exhibited as variations in the kinematics of movement. There were considerable differences between the style of one subject when compared to the other two over all the trials of each subject. This variation in style was most obvious in subject number PT who had a pumping style of push and recovery whereas subjects CA and GW employed a more continuous circular motion. The differences in the amount of forward lean of each subject were related to residual muscle strength. The discussion centered on the influence of the different styles on performance.

Bilateral wrist dislocation in an above knee amputee with advanced rheumatoid arthritis. Attempts at ambulation

The ambulatory difficulties of a patient with long standing rheumatoid arthritis with an above knee amputation and bilateral wrist dislocations has not been previously reported. Although wrist fusion did in fact increase his hand strength, control and stability, he still lacked sufficient hand strength and grip to don and doff the prosthesis, nor could he use assistive devices in order to become an independent ambulator. The results of wrist fusion and attempts at ambulation are discussed.

Functional cast-bracing for Colles' fractures. A comparison between cast-bracing and conventional plaster casts

The use of Orthoplast cast-bracing to allow early hand function in the treatment of displaced Colles' fractures was investigated in 243 patients. They were randomly allocated into three groups: in the first a conventional Colles' type plaster was used; in the second an above-elbow cast-brace with the forearm in supination; and in the third a below-elbow cast-brace. Radiographic measurements were made at each stage of treatment, and the final anatomical result was scored using Sarmiento's (1975) criteria. Function was assessed at three months and at six months. The anatomical result was not influenced by the method of immobilisation but was related to the efficacy of reduction. Loss of position in the braces was no greater than in plaster. The functional result at three months also was uninfluenced by the method of immobilisation; it was, however, related to the severity of the initial displacement, and (to a lesser degree) to the anatomical result, an effect which was lost at six months. Early hand function and the supinated position advocated by Sarmiento were found to confer no anatomical or functional advantage; we could see no reason to change from the use of conventional plaster casts in the treatment of uncomplicated Colles' fractures.

Intercarpal arthrodesis in the management of chronic carpal instability after trauma

A retrospective review of five patients with chronic carpal instability resulting from trauma suggests that this condition can be successfully treated by intercarpal arthrodesis. Scaphoid-lunate fusion was used to treat chronic dorsal intercalary segment instability, while scaphoid-capitate-lunate fusion was used to treat chronic palmar intercalary segment instability. Results after intercarpal arthrodesis were consistently good, with restoration of painless function, preservation of grip strength, and a high degree of patient satisfaction. Although a fibrous union was obtained in two of the three scaphoid-lunate arthrodeses, this did not prejudice a good clinical outcome. These results compare favorably to those with other treatment modalities, including ligamentous reconstructions with tendons. Based on these findings, a more extensive clinical trial of intercarpal arthrodesis to treat chronic carpal instability appears warranted.

Capitate-lunate instability: recognition by manipulation under fluoroscopy

Videotape fluoroscopy was used to diagnose a previously undescribed carpal dissociation, the capitate lunate instability pattern. In eight patients with midcarpal pain and clicking, the examiner simultaneously applied pressure to the scaphoid tuberosity while applying longitudinal traction and flexion to the wrist under fluoroscopic control. This maneuver revealed dorsal subluxation of the proximal carpal row and capitate lunate subluxation in each of the eight patients. Plain radiography and arthrography were not helpful in the diagnosis. All eight cases were managed conservatively. Videotape fluoroscopy is the best radiologic method of diagnosing capitate-lunate instability.

Total wrist arthroplasty. A clinical review

Since 1974, a cementable, semi-constrained total wrist prosthesis has been implanted in patients with advanced destruction of the carpus usually secondary to rheumatoid arthritis. The single most common problem observed after surgery in the first one hundred cases was that of ulnar deformity. Since 1977, 25 total wrist arthroplasties have been performed in 22 patients (3 bilateral cases). A modification of the original prosthesis was employed in these. The newer designs allow for the precise reduplication of the instant center of motion of the normal wrist. Additionally, in the last six patients operated on, methylmethacrylate cement was not used to secure the metacarpal component because a secure press-fit was possible in each case. To date, postoperative results have disclosed no cases of radial ulnar imbalance. No cases of dislocation, infection, or loosening have occurred. No difference in the degree of postoperative pain relief has been observed between those cases in which cement was employed to secure the prosthetic components and those cases in which cement was used only to secure the radial component.

Flexible implant arthroplasty of the radiocarpal joint. Surgical technique and long-term study

The wrist joint is frequently impaired in rheumatoid, post-traumatic, and degenerative arthritis. Stable radiocarpal motion, even limited, can improve functional hand adaptations, especially if the proximal or distal joints are disabled. A flexible silicone intramedullary stemmed hinged implant was developed in 1967 to be used as an adjunct to resection arthroplasty of the radiocarpal joint while at the same time maintaining the radiocarpal relation and allowing wrist motion in all planes. The surgical technique includes proper contracture release, bone preparation, extensor tendon repair and balancing, and dorsal and palmar capsuloligamentous repair to allow only 60 degrees of total passive flexion/extension and 10 degrees radial/ulnar deviation. This procedure can be combined with ulnar head capping. Metal bone liners (grommets) may be used to protect the radiocarpal implant from sharp bone edges. From January 1970 to April 1983, 181 wrist implant procedures had been performed in 139 patients, most of whom had rheumatoid arthritis. Stable, pain-free functional motion was obtained in the majority of cases. Roentgenograms showed the implants to be well tolerated by bone. Complications were infrequent. Because this procedure does not require cementing or significant bone resection, revision or arthrodesis procedures are facilitated.

Arthrodesis of the arthritic wrist

Although arthroplasty has developed tremendously in the last few years, there are still indications for arthrodesis of the wrist, particularly in nonrheumatoid patients where fairly heavy loads are imposed on the joint. Fusion is also a salvage procedure for failures of other procedures. The authors recommend fusion in a neutral position for unilateral or bilateral cases. Neutral is defined as 0 degree on the lateral with about 10 degrees ulnar deviation. This gives an arc of motion from pronation and supination, which substitutes for palmar flexion and dorsiflexion. The important factors in securing arthrodesis are: internal fixation with intramedullary pins, bony contact, bone graft if necessary, compression, and obtaining or maintaining rotation of the forearm. In selected cases arthrodesis of the wrist produces a very good result.

[Late functional results following replantation of a hand with resection of the proximal carpal row]

A total amputation through the proximal carpus is presented in a 10 year old boy. Replantation was performed following partial resection of the proximal carpal row with capsulorrhaphy, avoiding time-consuming osteosynthesis. The late result shows normal development of the hand and the preservation of wrist motion. For this reason conservation of the wrist joint especially in the growing skeleton should be preferred to a primary arthrodesis.

The painful wrist

Almost certainly, any condition producing pain in the wrist will interfere with the use of the hand. This in turn can cause impaired function of the whole of the limb.

Susceptibility of the superficial sensory branch of the radial nerve to form painful neuromas

The superficial sensory branch of the radial nerve appears prone to develop painful neuromas out of proportion to its likelihood for injury. Based on cadaver dissections and intraoperative observations, an anatomical mechanism for this "predisposition" is suggested. Exit of this nerve beneath dense fascia and the tendons of brachioradialis and extensor carpi radialis longus provide a proximal tethering against which tension develops as the distal fixation point (neuroma) is pulled through the long excursion of wrist arc of motion. This long excursion and proximal tethering are not present anatomically for the dorsal cutaneous branch of the ulnar nerve nor the palmar cutaneous branch of the median nerve.

Motor deficits in patients with large-fiber sensory neuropathy

The issue of whether brain signals in the absence of peripheral feedback are sufficient to specify accurate movement was evaluated by studying motor performance in patients with loss of somesthetic afferent input as a result of acquired large-fiber sensory neuropathy. With visual guidance, movements and postures were impaired relatively little, but when visual guidance was unavailable, the patients exhibited postural drift and gross inaccuracy of movement. Impairments were more apparent for smaller (3 degrees) than for larger (15 degrees) movements. Previous studies that have failed to show major motor impairments in deafferented subjects examined movements involving rather large joint displacements, and this may have been a factor in the failure of these studies to reveal severe deficits. The present results demonstrate a critical role for somesthetic feedback in regulating centrally generated levels of motor output and show that central motor programs deprived of such feedback are unable to subserve accurate motor control.

[Carpal instability--ligamentous instabilities and intracarpal malalignments--explication of the concept of carpal instability]

Normally, intracarpal stability is due to the carpal ligaments as well as to the "spatial coherence" of the carpal bones. "Destabilization" may be due to ligamentous attenuation when sprains and dislocations occur. This will lead to "dynamic instability" in extreme movements of the wrist or to malalignments in the case of long-standing dislocations. The scapholunar, triquetral or midcarpal ligamentous structures may be involved. The loss of spatial coherence by modifications in the form or in the volume of the carpal bones may lead to "compensatory carpal re- or malalignments".

Synovectomy with resection of the distal ulna in rheumatoid arthritis of the wrist

Wrist synovectomy with resection of the distal ulna was performed in 47 cases, where rheumatoid affection in the wrist joint caused visible capsular swelling, pain and reduced range of motion. At follow-up after a mean observation time of 33 months, 31 cases had complete pain relief, eight cases had moderate pain relief. In eight cases pain during wrist motion was unchanged at follow-up and in five of these, recurrence of capsular swelling was noted. The range of motion (both supination/pronation and vola- and dorsiflection) was significantly improved, as was the subjective assessment of function. The radiographic findings showed progression in 41 cases. Deviation in the wrist was unchanged. In three cases reoperations were performed and one case had spontaneous rupture of the 4th and 5th extensor tendons 1 month postoperatively. In 15 cases dislocation of the extensor carpi ulnaris tendon in volar direction by rotational movement was noted. Stability was good in all cases and no serious postoperative complications occurred. Wrist synovectomy with resection of the distal ulna is recommended in cases where regular medical treatment has been attempted for a minimum of 6 months without successful results.

Pressure and nerve lesion in the carpal tunnel

In 16 patients, where the diagnosis carpal tunnel syndrome was electrophysiologically confirmed, the pressure between the median nerve and the carpal ligament was measured peroperatively. At rest the pressure was 18-64 mmHg, mean 31 mmHg. Passive volar and dorsal wrist flexion increased the pressure about three times. Isometric or isotonic maximal contractions of wrist and finger muscles, elicited by tetanic nerve stimulation increased the pressure to three to six times the resting value. These high pressures may be one of the causes of the nerve lesion in the carpal tunnel syndrome.

Surgical treatment of the rheumatoid wrist

Normal wrist function must be understood if effective treatment is to be achieved in the rheumatoid wrist. Surgical treatment in this region is considered in two groups: 1. Synovectomy for prophylactic and symptomatic relief 2. Salvage procedures consisted of arthroplasties and arthrodesis in the severely destroyed joints to improve cosmetic appearance and offer some control over the finger functions.

Low profile dynamic splinting of the injured hand

Dynamic splinting is a well-accepted modality in gaining joint motion in the injured hand. Presented is a splinting design system referred to as "low profile" dynamic splinting whereby high outriggers are avoided. A review of the literature reveals that this technique is based on the original design approach used by Dr. Sterling Bunnell. Described are the basic principles of the low profile design system, with illustrations of the system in specific splints and specific construction details. This splinting system is indicated for a stiff hand that has sustained direct trauma. Hands with a muscle imbalance secondary to a central nervous system or peripheral nerve lesion require a different splinting approach, which is not within the scope of this paper.

Joint flexibilities in structurally normal girls and girls with idiopathic scoliosis

Seven clinical measurements of joint flexibilities were made in 51 girls with untreated mild idiopathic scoliosis and 65 girls with structurally normal spines. Subject ages ranged from 10 to 16 years. Abilities to have the index finger passively extended, the wrist bent, and the elbow and the knee hyperextended, along with abilities to bend the trunk voluntarily forward and to the right and left sides, were measured. The girls with scoliosis in the mean either had the same flexibilities or were less flexible than the normal girls. The study provided no evidence that untreated mild idiopathic scoliosis occurs or progresses because of increased joint flexibilities.

Osteoarthritis of the trapezio-metacarpal joint. Results of treatment with a silicone cap implant

The results of surgical treatment for arthritis of the first carpometacarpal joint using Kessler's silicone implant were examined in a group of 23 patients. The mean follow-up period was 24 months. Pain relief was obtained in 18 patients (78 per cent), functional improvement in daily activities in 16 patients, and power of pinch and power of grasp were improved in 10 out of 13 patients. Limitation of abduction complicated surgery in 6 patients. A high incidence of subluxation was found without correlation to the subjective results. Most of our patients were satisfied with the functional end results.

Principles and experimentation of wrist prostheses of the universal joint type

The till now wrist prosthesis have a poor rotatory stability either they are flexible or rigid; specially the spheric ones, they are unable, from their very conception, to transmit the pronation-supination; the condylar ones have an incomplete stability because of their insufficient embedding. The prono-supination transmission needs a "universal joint" prosthesis, whose sellar surfaces are deeply embedded; so, it is possible to get in the same time firm stability and normal ranges of motion. The articular components, crescent roll shaped, are chained each other in perpendicularly plans and fixed in the radius and in the carpus-metacarpus. This is the mono-articular prosthesis, radio-carpal, type A. With an ulna piece, articulated with the radial one by a spherical pivot, we have a bi-articular prosthesis, type B, including the lower radio-ulnar joint: so we have the true total wrist prosthesis. Experimented on cadaveric specimens, these two prostheses, inserted by dorsal approach, have physiologic ranges of motion and absolute rotatory stability. Further studies may define the best dimensions of the prosthesis according to individual variations and ancillary tools set, before beginning the clinical experimentation.

The effect of the Futuro wrist brace in pain conditions of the wrist

In a study to assess the effects of the Futuro wrist brace (Adcock-Ingram) in 22 patients with osteoarthritis, rheumatoid arthritis, tenosynovitis and gout of the wrist, grip and pinch dynamometers were used to measure improvement in function. The study confirmed the efficacy of the wrist brace by demonstrating an average of 23.7% improvement in grip strength over the 10-day study, as well as a significant average improvement in pinch strength of 14.8% (P less than 0.05). In the subgroup of 8 rheumatoid arthritis patients a significant average increase in grip strength of 48.9% (P less than 0.025) was obtained. Both day and night pain was reduced and there was improvement in patients' ability to carry out their daily activities. The brace was found to be comfortable and easy to use.

Tension band wiring for fixation of comminuted fractures of the distal radius

In the treatment of unstable comminuted and intra-articular fractures of the lower end of the radius, we have found that is is essential to reconstitute the normal anatomical relationship of the radius to the carpus and to the ulna. This is possible by performing an open reduction and by maintaining the fractured fragments by Kirschner wires and adding a tension band. Patients treated thus are reported. There have been no complications and the patients regained full function of the wrist without unsightly deformity.