Obstetrical brachial plexus palsy: lessons in functional neuroanatomy

Obstetrical branchial plexus paralysis is a serious and possibly disabling disorder. While thoroughly described as a clinical entity, much concerning its pathogenesis is still unknown. Basic science studies alongside with studies on functional neuroanatomy of peripheral and central nervous system and their interactions lead to deeper understanding of its pathology. Research concentrates on the consequences of branchial plexus traction to peripheral nerves and muscles function and viability and rehabilitation options. Changes obstetrical branchial plexus paralysis causes to central nervous systems organisation have been, to some extent, investigated. It seems that central nervous system is not "blind" after obstetrical branchial plexus paralysis but instead proceeds to remodelling so to adapt to new needs. Research indicates that both this entity and organism's response are much more complicated than previously believed. Current treatment options include microsurgery and palliative surgery but their improvement is possible by focusing on central nervous system. Current report discusses these topics and tries to reach useful conclusions.

Surgical technique: Tibia cortical strut autograft interposition arthrodesis after distal radius resection

BACKGROUND

Distal radius reconstruction after en bloc tumor resection remains a surgical challenge. Although several surgical techniques, either reconstructing the wrist or achieving a stable arthrodesis, have been described, it is unclear to what degree these restore function.

DESCRIPTION OF TECHNIQUE

We describe an updated technique making use of a tibia cortical strut autograft (TCSA) to perform a functional arthrodesis from the remaining radius to the first carpal row. This, in theory, could lead to less donor site morbidity while resulting in a stable but functional and pain-free arthrodesis of the wrist.

METHODS

Between 1987 and 2010 we reconstructed the wrists of 17 patients using a TCSA arthrodesis (six primary and three revisions), seven with an osteoarticular allograft, three using an ulnar translocation, and one with a fibula autograft. Median age at diagnosis was 24 years (range, 9-58 years) and minimum followup was 2.7 years (median, 13.8 years; range, 2.7-24.5 years). Patients were evaluated using radiographs and clinical examination. We used Musculoskeletal Tumor Society (MSTS), Disabilities of the Arm, Shoulder, and Hand (DASH), and SF-36 questionnaires to assess function and quality of life.

RESULTS

All TCSA reconstructions fused; one patient had a second surgery to expedite union with the carpal row. After osteoarticular allograft, five patients were revised (three to a TCSA) for nonunion, fracture, or joint collapse. ROM and grip strength were comparable in both AO and TCSA, all above 60% of the contralateral side. Median MSTS and DASH scores were 73% and 6, respectively, and did not differ between the groups. The SF-36 scores showed less pain after TCSA; otherwise, all patients presented with comparable function.

CONCLUSIONS

TCSA wrist arthrodesis resulted in a functional and painless wrist reconstruction with a relatively low complication and donor site morbidity rate and comparable functional results as other techniques.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Volar long locking compression plate fixation for distal radius fractures with metaphyseal and diaphyseal extension

Comminuted distal radial fractures with metaphyseal and diaphyseal extension are uncommon and remain a challenge to treat. The purpose of this study was to assess the radiographic and functional outcomes of treatment with the volar long locking compression plate (LCP) system for distal radius fractures with metaphyseal and diaphyseal extension. This retrospective study was performed on 22 consecutive patients who were treated with open reduction and internal fixation with the application of a 2.4-mm-extra-long LCP volar distal radius plate. Patients were evaluated based on clinical signs and radiography studies. The average time to fracture union was 16 weeks. The volar tilt was restored to a mean of 10.1°. The radial length and radial inclination were restored to a mean of 12.8 mm and 23.6° at final follow-up, respectively. The mean loss of radial length was -1.0 mm at final follow-up as compared with the contralateral extremity. The average ulnar variance was positive 0.1 mm at final follow-up with a congruent distal radioulnar joint. The degree of collapse after fixation between immediate postoperative and final follow-up visit was -0.1 mm. Using the demerit-point system of the Gartland and Werley rating system, 14 results were rated as excellent, 5 as good and 1 as fair. DASH scores averaged 10.1 points. Based on our experience, the volar long LCP is useful in the management of comminuted fractures of the distal radius, in which there is proximal extension into the diaphysis and can avoid or minimize the complications of external fixation or dorsal bridging distraction plate.

Outcome of treatment of complex, perilunate fracture-dislocation of the wrist: a case report

Complex, perilunate fracture-dislocations of the wrist comprise severe and challenging injuries, characterised by a total loss of contact between the lunate bone and the head of the capitate as well as fracture of one, or more bones surrounding lunate bone. The principle of treatment of such injuries involves stable fixation of fractures, anatomical reduction of the displaced carpal bones with temporary arthrodesis wit K-wires to maintain their position. We present a patient who sustained a complex, perilunate fracture-dislocation of the wrist with fractures of the scaphoid, hamate and base of the IV metacarpal bone, as a result of a blast. Assessment at one year after the surgery showed satisfactory result: mean range of motion in the wrist was 50-60% of the healthy side, grip strength was 55%, DASH score of 36 and Mayo score of 65.

Thermal energy for the arthroscopic treatment of tears of the triangular fibrocartilage of the wrist

We evaluated the clinical and occupational outcomes of arthroscopic treatment with electrothermal shrinkage for triangular fibrocartilage complex (TFCC) tears. We retrospectively reviewed 162 patients. All patients had ulnar-sided wrist pain that limited their occupational and sporting activities. The surgical technique consisted of electrothermal collagen shrinkage of the TFCC. Pain relief, range of motion, complications, reoperation rate, time to return to work and workers' compensation claims were evaluated. Exclusion criteria were distal radioulnar joint instability and association of other wrist lesions. Complete pain relief was noted in 80.3% of the patients, incomplete pain relief in 14.8%, and only 4.9% required reoperation because of pain-persistence. The average range of motion was over 90% compared to the opposite hand. Worker's compensation claims were introduced by 20 patients, of which 6 did not return to their previous occupation. Electrodiathermy may be a useful option for arthroscopic treatment of TFCC tears in cases without distal radioulnar joint instability.

Results of ulnar shortening osteotomy for ulnocarpal abutment after malunited distal radius fracture

Surgical correction for ulnocarpal abutment syndrome after malunited distal radius fracture remains controversial. We reviewed sixteen patients (7 men, 9 women) who underwent isolated ulnar-shortening osteotomy for ulnar wrist pain as their main complaint. Mean age was 48 years. The range of flexion-extension increased from 81 degrees to 103 degrees, and range of supination-pronation from 120 degrees to 142 degrees after osteotomy. Mean grip strength increased from 49% to 69%. Mayo wrist score was excellent in 2 cases, good in 7 cases, fair in 6 cases, and poor in 1 case. Grip strength was found to correlate with radial inclination and flexion-extension range with the amount of ulna shortening.

Results of the Max Page muscle sliding operation for the treatment of Volkmann's ischemic contracture of the forearm

BACKGROUND

Volkmann's ischemic contracture is a less common but crippling condition affecting the extremities. Once the condition sets in, the prognosis always remains guarded, even after long and intensive physiotherapy and various restorative surgical techniques. This study was undertaken to evaluate the long-term functional results of the Max Page muscle slide operation in patients with Volkmann's ischemic contracture of the forearm of moderate degree (Tsuge classification).

MATERIALS AND METHODS

Nineteen patients treated between 1997 and 2009 were evaluated. The functional outcome (measured as the dexterity score, hand grip strength, sensibility, and appearance) was analyzed postoperatively. The pre- and postoperative values were compared using a paired t test. The final results were graded as good, fair, and poor.

RESULTS

The average age at the time of presentation was 18 years (range 3-25 years). Tight external splintage for injuries around elbow and forearm was the primary factor. The mean period of follow-up was 3.53 years. Fifteen patients were able to achieve good functional results. Three had fair and one had poor results. All three variables showed significant improvements postoperatively. Wound dehiscence was the most common complication. One patient needed a second surgery to restore good hand function.

CONCLUSION

The Max Page muscle sliding operation to treat Volkmann's ischemic contracture of moderate degree gives good functional results. The procedure is simple and easy to perform. Adequate muscle release and proper postoperative physiotherapy are key to achieving good results.

Arthroscopic resection arthroplasty for malunited intra-articular distal radius fractures

PURPOSE

Cartilage damage of the carpals is a contraindication for corrective osteotomy of the malunited intra-articular distal radius fracture and typically is treated in the symptomatic patient with a salvage procedure. Here, we present our experience and early results with arthroscopic resection arthroplasty of the radiocarpal joint.

METHODS

We treated 10 patients (age, 17-68 y; average, 53 y) who had intra-articular malunion of the distal radius with mirror erosion on the carpals. The original fracture occurred 4 to 36 months (average, 9 mo) before our intervention. We performed arthroscopic arthrolysis and resected the offending portion of the radial malunited fragment, eliminating the stepoff and creating a smoother joint surface. Range of motion was started immediately after the operation, except in 2 patients.

RESULTS

The locations of the malunions were evenly distributed between the scaphoid fossa, the lunate fossa, or both. Stepoffs varied from 2 to 6 mm. We resected up to 60% of the entire radial articular surface to obtain a smooth surface (average, 28%; range, 20% to 60%). All patients reported immediate relief of pain and improvement in motion (particularly extension). At the latest follow-up (average, 28 mo; range, 13-42 mo), average extension improved from 24° to 54°, average grip strength improved from 47% to 89% of the contralateral wrist, average Disabilities of the Arm, Shoulder, and Hand score improved from 74 to 18, and average Patient-Rated Wrist Hand Evaluation score improved from 79 to 15.

CONCLUSIONS

The aim of the operation was to relieve patients' pain by providing a smooth, although fibrocartilaginous, surface for the carpus to glide on the radius. The follow-up was short and the results may be short-lived. However, for the younger patient, it may provide a temporary alternative to partial wrist arthrodesis with minimal morbidity, and for the less demanding patients, it may be a definitive procedure.

Radial inclination and palmar tilt as risk factors for Kienböck's disease

Radial inclination angle (RIA) and palmar tilt (PT) of distal articular surface of radius, are anatomical factors that influence force transmission across the wrist and load transfer to the lunate. The purpose of this study is to evaluate the relationship between these parameters and Kienböck's disease. We measured and compared RIA and PT in standard posteroanterior and lateral wrist x-rays of 55 patients with Kienböck's disease and 60 controls. The mean RIA was 25.5° in Kienböck's disease patients and 23.3° in the control group (P = .002). The mean PT was 11.5° and 9.4° for patients and controls, respectively (P = .005). All of these differences were statistically significant. We concluded that there is an etiological association between higher degrees of RIA and PT with Kienböck's disease.

An evaluation of operative management of displaced volar Barton's fractures using volar locking plate

Volar Barton's fractures are common but more convincing treatment methods are still controversial. Malunion can cause serious disability. Twenty-six consecutive patients were treated with open reduction Internal fixation using volar locking plate. Records of 21 cases were available for follow-up for a mean period of 18 months (range 12-34 months). All 21 fractures healed within 8 to 14 weeks (mean 9.3 weeks). The wrist function was satisfactory in 90.4% cases (19 out of 21 patients). This surgical technique can provide high success rate. Locking plate has better efficacy in terms of immediate stability, maintaining anatomic reduction and early mobilisation.

Results after radioscapholunate arthrodesis with or without resection of the distal scaphoid pole

PURPOSE

To evaluate the differences between radioscapholunate (RSL) arthrodesis alone versus RSL arthrodesis with additional distal scaphoidectomy.

METHODS

We retrospectively evaluated 61 patients who were treated with RSL arthrodesis for painful posttraumatic osteoarthritis. Thirty patients had an RSL arthrodesis with additional resection of the distal scaphoid pole (group A), and 31 had RSL arthrodesis alone (group B). Six patients in group A and 8 in group B had the RSL arthrodesis converted to a complete wrist arthrodesis during follow-up. Those patients were excluded from the survey. Of the remaining 47 patients, 35 (20 from group A, 15 from group B) returned for a clinical and radiological examination at an average of 28 (range, 10-47) months after the index surgery. The results were rated by the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. The patients' outcomes after RSL arthrodesis with or without distal scaphoidectomy were compared for pain, wrist motion, grip strength, nonunion rate, osteoarthritis of the adjacent joints, the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score.

RESULTS

Three patients with RSL arthrodesis alone showed a radioscaphoid nonunion. All arthrodeses in group A healed. In the clinical evaluation, there was no significant difference between groups A and B in the Disabilities of the Arm, Shoulder, and Hand score, the modified Mayo Wrist Score, grip strength, pain, or wrist motion. Assuming that wrist motion might be better in patients with a nonunion, the average wrist motion was recalculated after eliminating 3 patients with a radioscaphoid nonunion from group B. Radial deviation was then found to be significantly better in group A.

CONCLUSIONS

Additional distal scaphoidectomy with RSL arthrodesis seems to improve postoperative radial deviation of the wrist. The radioscaphoid nonunion rate is high with RSL arthrodesis alone. Distal scaphoidectomy appeared to increase the successful fusion rate of RSL arthrodeses. No significant effect on wrist extension, flexion, ulnar deviation, pain level, restriction in activities of daily living, or grip strength was noted.

[Treatment of type c fractures of the distal radius with volar locking compression plate and radial styloid process plate]

OBJECTIVE

To analyze the effectiveness ofvolar locking compression plate (LCP) and radial styloid process plate for the treatment of type C fractures of the distal radius.

METHODS

Between May 2010 and May 2011, 24 cases of type C fractures of the distal radius were treated, including 8 males and 16 females with an average age of 52 years (range, 23-73 years). Injury was caused by falling in 20 cases and by traffic accident in 4 cases. All were fresh closed fractures. The locations were the left side in 15 cases and the right side in 9 cases. According to AO typing, there were 16 cases of type C2 and 8 cases of type C3. The preoperative palmar tilt angle ranged from 60 to 25 degrees (mean, -45.3 degrees); the preoperative ulnar inclination angle ranged from 16 to 13 degrees (mean, 8.2 degrees); and the preoperative radial length shortening was 8-18 mm (mean, 12 mm). The time from injury to operation was 3-10 days (mean, 5.2 days).

RESULTS

All operation incisions healed primarily. All patients were followed up 9-16 months (mean, 13.5 months). The healing time of fracture was 8-12 weeks (mean, 10.2 weeks). The articular surface was smooth and the radial length was recovered. The postoperative palmar tilt angle ranged from 8 to 15 degrees (mean, 12.3 degrees); the postoperative ulnar inclination angle ranged from 18 to 26 degrees (mean, 22.3 degrees). No loss of reduction, refracture, or carpal tunnel syndrome occurred during follow-up. The average range of motion of the wrist was 45.3 degrees (range, 30-70 degrees) in dorsal extension, was 50.2 degrees (range, 26-78 degrees) in palmar flexion, was 13.5 degrees (range, 8-25 degrees) in radial inclination, was 23.6 degrees (range, 15-32 degrees) in ulnar inclination, was 65.7 degrees (range, 35-90 degrees) in pronation, and was 72.5 degrees (range, 20-90 degrees) in supination at last follow-up. According to the wrist function by Gartland-Werley scoring, the results were excellent in 12 cases, good in 8 cases, and fair in 4 cases; and the excellent and good rate was 83.3%.

CONCLUSION

Treatment of type C fractures of the distal radius with volar LCP and radial styloid process plate can reconstruct normal anatomic structures and get good functional recovery.

In vivo changes in contact regions of the radiocarpal joint during wrist hyperextension

PURPOSE

Distal radius and scaphoid fractures commonly occur after a fall with the hand outstretched and wrist hyperextended. We investigated contact characteristics of the radiocarpal joint in neutral position, hyperextension, and hyperextension combined with radial deviation in vivo.

METHODS

Eight volunteers without a known history of wrist injury were enrolled. We obtained computed tomography scans with 3-dimensional reconstructions of the subjects' right wrists in neutral, hyperextension, and hyperextension with 10° of radial deviation. The contact regions of the radiocarpal joint were mapped. The direction and distance of changes in the contact region centers were recorded and analyzed.

RESULTS

From neutral position to hyperextension, the contact of the scaphoid substantially shifted from the middle to the dorsal part of the articular surface of the radius in 5 of the 8 wrists. With these wrists further deviated radially, the contact shifted to the surface over the radial styloid. In the other wrists, the contact of the scaphoid remained in the center of the radial articular surface. In all wrists, the contact of the radius on the scaphoid shifted from the proximal lateral surface of the scaphoid to the proximal dorsal surface of the scaphoid, and the contact of the radius on the lunate shifted dorsally.

CONCLUSIONS

During wrist hyperextension, the contact of the scaphoid on the distal radius exhibited 2 possible types of changes: either shifting from the mid-portion to the dorsal ridge of the articular surface of the radius or remaining at the center of the articular surface. Combined wrist hyperextension with radial deviation caused the scaphoid to contact the radius over the radial styloid. The contact of the radius on the scaphoid shifted from proximal lateral to proximal dorsal scaphoid, and that on the lunate shifted dorsally.

CLINICAL RELEVANCE

This study provided in vivo mechanical findings to improve our understanding of the mechanism of hyperextension injuries of carpus.

Quantification of periarticular demineralization and synovialitis of the hand in rheumatoid arthritis patients

The bone mineral density (BMD) measurement of the hand in rheumatoid arthritis (RA) patients is no standard measurement method as yet. The aim was to contribute to the standardization of the hand BMD measurement, especially of periarticular regions. As results, we found best precision values for the wrist and a significant correlation between hand and spine/femur BMD depending on disease activity and disease duration.

INTRODUCTION

This study was conducted to investigate (i) the precision of periarticular hand BMD measuring, (ii) the periarticular demineralization of the hand, (iii) the correlation between periarticular hand BMD and spine/femur BMD, and (iv) the correlation of hand BMD to hand synovitis.

METHODS

A number of 52 RA patients were examined by BMD measurement of the femoral neck, spine, whole hand, metacarpophalangeal (MCP) joints II-V, personal identity profile (PIP) joints II-V, and wrist using dual-energy X-ray absorptiometry (DXA). Synovitis of the hand was examined by ultrasonography and magnetic resonance imaging (MRI). Three subgroups were further analyzed: early RA, established RA with moderate and with high disease activity. Early RA and established RA patients with high disease activity were Followed up after 12 months.

RESULTS

We found (1) best precision of BMD measurement for the wrist, (2) BMD in RA significantly reduced if compared to normal controls, (3) a highly significant positive correlation between hand and spine/femur BMD and the power of correlation to depend on disease activity and disease duration (high correlation in RA with moderate disease activity and early RA, very high correlation in RA with high disease activity), (4) a negative correlation between hand BMD and hand synovitis in RA with high disease activity, and (5) a significant reduction of synovitis but no change in hand BMD after 12 months, respectively.

CONCLUSIONS

This study shows a highly significant correlation between hand BMD and spine/femur BMD in RA patients depending on disease activity and disease duration. We conclude to measure BMD at different sites including hands in order to quantify bone loss in RA patients most properly.

Pulsed electromagnetic field during cast immobilization in postmenopausal women with Colles' fracture

INTRODUCTION

Although Colles' fracture i.e. a dorsally displaced distal radius fracture (DRF) is one of the most common fractures, there is no enough evidence to determine the best form of rehabilitation.

OBJECTIVE

To assess whether the use of pulsed electromagnetic field (PEMF) therapy during cast immobilization of DRF provides beneficial effects on pain, edema, wrist range of motion and function, as well as on the frequency of complications immediately after cast removal.

METHODS

The prospective randomized controlled study included 60 women over the age of 55 years with extra-articular displaced DRF treated with reduction and cast immobilization. The patients were alternately allocated to either a PEMF group (n = 30, received 10 days of PEMF therapy during immobilization), or a control group (n = 30, without PEMF therapy). Pain, function, hand circumference, wrist and forearm range of motion and frequency of complications for each patient was evaluated within two to three days of cast removal.

RESULTS

Better mean values for the majority of examined parameters were recorded in the PEMF group than in the control group, but the difference was statistically significant just for edema (p < 0.001), flexion, extension and supination range (p < 0.01).

CONCLUSION

During immobilization PEMF therapy in DRF patients gave better results immediately after cast removal in terms of edema and wrist range of motion (ROM).

Distal radius definitive epiphysiodesis for management of Kienböck´s disease in skeletally immature patients

PURPOSE

Kienböck's disease is an unusual pathology with unknown aetiology within the pediatric population. Several treatment options have been described in the literature; however, there are neither large series nor homogeneous studies that have clarified which treatment is best. The aim of this study was to describe five cases in which definitive distal radius epiphysiodesis was performed as an alternative method to the classic distal radius shortening osteotomy in skeletally immature patients with Kienböck's disease.

METHODS

The clinical charts and radiographs of four patients (five wrists) diagnosed as having Kienböck's disease and treated by definitive distal radius epiphysiodesis were reviewed.

RESULTS

All patients were symptomatically free with full range of motion at 4.25 months (range, three to six months) after surgery. In all cases, shortening of the distal radius was achieved (p = 0.032).

CONCLUSIONS

This new technique is a simple, effective, and minimally invasive procedure with low morbidity and good clinical and radiological outcomes.

A follow-up association study of two genetic variants for bone mineral density variation in Caucasians

SUMMARY

We tested whether two genetic variants were associated with BMD at multiple clinically relevant skeletal sites in Caucasians. We found that variant rs7776725 is consistently associated with hip, spine, wrist and whole-body BMD, which highlights the potential importance of this variant or linked variants for osteoporosis.

INTRODUCTION

A recent genome-wide association study identified two single nucleotide polymorphisms (SNPs), rs7776725 and rs1721400, that were associated with bone mineral density (BMD) variation at the radius, tibia and calcaneus in a Korean population. In this study, we aimed to test whether the association of these two genetic variants can be replicated in Caucasians and whether their association with BMD can be extended to other clinically relevant skeletal sites.

METHODS

We performed this study in two large cohorts of unrelated US Caucasians. Area BMD at the hip, spine, wrist (ultra-distal radius) and whole body were measured with Hologic dual-energy X-ray absorptiometer. SNPs were genotyped with Affymetrix human genome-wide genotyping arrays. Association analyses were performed using PLINK.

RESULTS

We detected highly significant association (combined p = 1.42 × 10(-16)) of rs7776725 with wrist BMD but only borderline association signal (combined p = 0.017) for rs1721400 with wrist BMD. In addition, we found that rs7776725 was associated with BMD at the hip, spine and whole body. At the FAM3C gene locus where rs7776725 was located, we identified several other SNPs (rs4727922, rs1803389, rs718766 and rs7793554) that were also associated with BMD.

CONCLUSIONS

This is the first follow-up association study of rs7776725 and rs1721400 with BMD. The rs7776725 showed consistent association with BMD at multiple clinically important skeletal sites, which highlighted the potential importance of rs7776725 or linked SNPs for risk of osteoporosis. Further in-depth re-sequencing studies and functional assays are necessary to elucidate the underlying mechanisms.

[Effect of associated ulnar styloid fracture on wrist function after distal radius]

OBJECTIVE

To evaluate the effect of associated ulnar styloid fracture on wrist function after distal radius fracture by comparing the clinical data between the cases of distal radius fracture with or without ulnar styloid fractures.

METHODS

The clinical data of 182 patients with distal radius fracture between February 2005 and May 2010 were retrospectively analyzed, including 75 with ulnar styloid fracture (group A), and 107 without ulnar styloid fracture (group B). There was no significant difference in sex, age, disease duration, and fracture classification between 2 groups (P > 0.05). In groups A and B, closed reduction and splintlet or cast fixation were performed in 42 and 63 cases respectively, and open reduction and internal fixation in 33 and 44 cases respectively. All ulnar styloid fractures were not treated.

RESULTS

The patients were followed up 21 months on average in group A and 20 months on average in group B. All incisions healed by first intention after operation. Ulnar wrist pain occurred in 4 patients (5.3%) of group A and 6 patients (5.6%) of group B, showing no significant difference (chi2=0.063, P=0.802). The fracture healing time was (10.9 +/- 2.7) weeks in group A and (11.6 +/- 2.3) weeks in group B, showing no significant difference (t=1.880, P=0.062). There was no significant difference in the palmar tilt angle, the ulnar inclination angle, and the radial length between groups A and B when fracture healing (P > 0.05). At last follow-up, there was no significant difference in wrist flexion-extension, radial-ulnar deviation, pronation-supination, and grip and pinch strength between 2 groups (P > 0.05). According to the Gartland-Werley score in groups A and B, the results were excellent in 24 and 35 cases, good in 43 and 57 cases, fair in 5 and 10 cases, and poor in 3 and 5 cases with execllent and good rate of 89.3% and 86.0%, respectively, showing no significant difference between 2 groups (Z=0.203, P=0.839). There were significant differences in the above indexes between patients undergoing closed reduction and open reduction in group A (P < 0.05).

CONCLUSION

Associated ulnar styloid fracture has no obvious effect on the wrist function after distal radius fracture. The anatomical reduction of distal radial fracture is the crucial importance in the treatment of distal radial fracture accompanying ulnar styloid fracture.

How to measure outcomes of distal radius fracture treatment

There is no established outcome measure designated as the superior measure when evaluating the results of distal radius fracture management. Although there are many used in the literature, there are only a few that have been validated to specifically predict recovery after a distal radius fracture. Additionally, there are few comparative trials that attempt to directly measure the predictive abilities of specific outcome measures. This article discusses the common scales and scores used to measure the functional recovery after distal radius fracture management and provides evidence-based literature to assess the reliability of these measures to predict outcomes.

Recovery after fracture of the distal radius

Stretching exercises are an important part of recovery after sustaining a fracture of the distal radius. However, from the patient's perspective, painful stretching exercises can be counterintuitive after injury. Stretching exercises are straightforward and do not require a significant amount of coaching. It is ultimately the protectiveness, passivity, and sometimes a sense of futility that require coaching. The key for the provider is to empathize with the difficult and counterintuitive nature of the recovery process.

PAEDIATRIC GALEAZZI-EQUIVALENT FRACTURE: TWO CASE REPORTS

The authors present two rare cases of a paediatric Galeazzi-equivalent fracture. In contrast to Galeazzi's fracture-dislocation in adults, an epiphyseal separation of the distal ulna occurred instead of dislocation of the distal radioulnar joint (DRUJ) or both. A precise radiographic analysis of the epiphyseal separation of the distal ulna and its anatomical reduction were keys to obtaining a good result in the treatment of paediatric Galeazzi-equivalent fracture.

Description, reliability and validity of a novel method to measure carpal tunnel pressure in patients with carpal tunnel syndrome

Elevated carpal tunnel pressure is an important pathomechanism in carpal tunnel syndrome (CTS). Several invasive methods have been described for direct measurement of carpal tunnel pressure, but all have two important limitations. The pressure gauge requires sterilisation between uses, which makes time-efficient data collection logistically cumbersome, and more importantly, the reliability of carpal tunnel pressure measurements has not been evaluated for any of the methods in use. This technical note describes a new method to measure carpal tunnel pressure using inexpensive, disposable pressure sensors and reports the within and between session reliability of the pressure recordings in five different wrist positions and during typing and computer mouse operation. Intraclass correlation coefficients (ICC[3,1]) were calculated for recordings within one session for healthy participants (n = 7) and patients with CTS (n = 5), and for recordings between two sessions for patients with CTS (n = 5). Overall, the reliability was high. With the exception of two coefficients, the reliability of the recordings at different wrist angles varied from 0.63 to 0.99. Reliability for typing and mouse operation ranged from 0.86 to 0.99. The new method described in this report is inexpensive and reliable, and data collection can be applied more efficiently as off-site sterilisation of equipment is not required. These advances are likely to promote future research into carpal tunnel pressure, such as investigation of the therapeutic mechanisms of various conservative treatment modalities that are believed to reduce elevated carpal tunnel pressure.

Osteopathic manipulative medicine for carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is 1 of the most common peripheral nerve entrapment disorders. Osteopathic manipulative medicine can be invaluable in diagnosing and managing CTS. Combined with a patient's history and a standard physical examination, an osteopathic structural examination can facilitate localizing the nerve entrapment, diagnosing CTS, and monitoring the disease process. Osteopathic manipulative treatment is noninvasive and can be used to supplement traditional CTS treatment methods. The authors also review the relevant anatomy involving CTS and the clinical efficacy of osteopathic manipulative medicine in the management of this disorder.

Arthroscopic treatment of peripheral triangular fibrocartilage complex tears with the deep fibers intact

PURPOSE

We describe a variant of triangular fibrocartilage complex (TFCC) tears in which the superficial fibers attaching to the ulnar capsule are torn, with preservation of deep fibers inserting on the fovea. We present the clinical and magnetic resonance imaging findings and the results of arthroscopic repair in patients with this injury.

METHODS

Twenty-nine wrists were treated arthroscopically for peripheral TFCC tears with outside-in suture repair of the TFCC to the ulnar capsule. A retrospective review of all cases was performed to assess the physical examination, magnetic resonance imaging, and intraoperative findings. Patients were evaluated at greater than 1 year with range of motion, grip strength, standard outcome measures, and a survey assessing return to work and sports.

RESULTS

Before surgery, all patients had complaints of ulnar-sided wrist pain with a stable distal radioulnar joint on examination. Twenty-six wrists (90%) were available for follow-up at a mean of 31 months. There was one repeat surgery, a re-tear that required revision TFCC repair. The preoperative visual analog scale and Disabilities of the Arm, Shoulder, and Hand scores improved from 5 and 38 to 1 and 9, respectively, at final follow-up. Side-to-side comparisons demonstrated no measurable loss in motion or grip strength. There were no cases of distal radioulnar joint instability at final follow-up. Of 11 high-level athletes in the total cohort, 7 (64%) were able to return to sports, including all of those in racquet sports; however, athletes who bore weight through their hands were unable to return to their sporting activity.

CONCLUSIONS

Tears of the TFCC superficial fibers with the deep fibers intact present with ulnar-sided wrist pain but without distal radioulnar joint instability. The results of outside-in repair of the articular disk back to the ulnar capsule demonstrated improvement in pain and function with no measurable objective losses. Return to sport was variable and appeared worse for those who bear weight through the hands.

Scaphoid excision and midcarpal arthrodesis: the effect of triquetral excision--a biomechanical study

PURPOSE

To evaluate the biomechanical alterations that occur after traditional scaphoid excision and midcarpal arthrodesis with and without excision of the triquetrum. The hypothesis of this study was that removal of the triquetrum increases the radiolunate contact pressure.

METHODS

We cyclically moved 10 fresh cadaver wrists using a wrist joint motion simulator while measuring the contact pressures between the proximal carpal row and the distal radius and ulna using a dynamic pressure sensor. We acquired data in the intact wrist, after a midcarpal arthrodesis with the scaphoid excised, and then again with the triquetrum removed, which is also known as a capitolunate arthrodesis.

RESULTS

The peak pressures in the radiolunate fossa significantly increased with either of the midcarpal arthrodeses compared with the intact wrist during each of the 3 dynamic wrist motions. In comparing the 2 midcarpal arthrodeses, the peak pressure in the ulnocarpal fossa significantly decreased after the triquetrum was removed during wrist radioulnar deviation and in the static ulnarly deviated position. After arthrodesis, we could identify no differences during any motion or static wrist position in the peak radiolunate pressures with or without the triquetrum.

CONCLUSIONS

We found that scaphoid excision and 4-corner arthrodesis shifts loads to the radiolunate joint. Isolated capitolunate arthrodesis with excision of the scaphoid and triquetrum further alters carpal kinematics and loading patterns.

CLINICAL RELEVANCE

These findings raise concern about routine excision of the triquetrum when performing a midcarpal arthrodesis.

Results of volar locking plating for unstable distal radius fractures

OBJECTIVE

The aim of this study was to analyze the complications and functional and radiographic results of volar locking plating in the treatment of unstable distal radius fractures.

METHODS

Forty-six patients (mean age: 48.7 years) with Type C distal radius fractures were treated with volar locking plates and evaluated over a mean follow-up period of 19 months. Range of motion, strength, DASH questionnaire and MAYO wrist score were assessed. Shortening, inclination and palmar tilt were recorded on standard radiographs and tenosynovitis and tendon ruptures were assessed using ultrasound. The uninjured wrists were examined as controls. Statistical analysis was made using t-tests.

RESULTS

All fractures achieved union. Postoperative MAYO scores revealed 14 excellent results, 11 good, 20 satisfactory and one poor result. The mean postoperative DASH score was 15.9 (range: 0 to 72). Active wrist motion averaged 52.3 degrees of flexion, 57.7 degrees of extension, 79.2 degrees of supination and 79.3 degrees of pronation. Mean grip strength was 82% of the uninjured side and mean loss of radial inclination was 0.6 degrees and palmar tilt was 6.6 degrees as compared to normal side. Carpal tunnel syndrome was observed in one patient, flexor tenosynovitis in one patient, extensor tendon rupture in one patient and extensor tenosynovitis in eleven patients. Functional and clinical limitations were most evident in the patients with tendon tear or tenosynovitis.

CONCLUSION

Fixation of unstable distal radius fractures with volar locking plates provides sufficient stability, and satisfactory clinical outcomes. However, these systems have complication potential that may limit better outcomes.

Radial and volar perilunate trans-scaphoid fracture dislocation: a case report

A case of radial and volar perilunate trans-scaphoid fracture dislocation in which the proximal fragment of the scaphoid was dislocated dorsally is presented.

Wrist arthroscopy in children and adolescents: a single surgeon experience of thirty-four cases

PURPOSE

The purpose of this study was to report our experience of wrist arthroscopy in children and adolescents with chronic wrist pain in a retrospective single surgeon series. Therefore, technical differences or obstacles compared to standard wrist arthroscopy in adults, and complications were highlighted.

METHODS

A retrospective data review of all patients undergoing wrist arthroscopy between 2002 and 2011 was performed. The basic inclusion criteria was chronic, therapy refractory wrist pain for more than three months in children and adolescents aged 18 years and younger. In total, 34 arthroscopies in 27 girls and six boys were reviewed. The mean age at time of arthroscopic exploration was 14.6 years (range, 9.8-17.9 years).

RESULTS

A total of 28 wrists showed a triangular fibrocartilage complex (TFCC) tear (82.4%). In 26 of 34 (76.5%) inspected wrist joints additional pathologies besides TFCC tears were documented. As a consequence, 14 arthroscopic TFCC resections, two arthroscopic TFCC repairs and seven open resection arthroplasties were performed. Other concomitant procedures (e.g., ulna shortening) were performed in 25 patients (26 wrists) because of predisposing malformations. No intraoperative or postoperative complications related to the arthroscopies were observed. No relevant technical differences to wrist arthroscopy in adults were experienced apart from cases of major anatomical malformations.

CONCLUSIONS

Wrist arthroscopy has been shown to be a safe procedure to detect and treat paediatric wrist disorders. Nevertheless, we believe that this procedure should only be carried out by well-trained, experienced hand surgeons.

ARTHROSCOPICALLY ASSISTED REDUCTION WITH VOLAR PLATING OR EXTERNAL FIXATION FOR DISPLACED INTRA-ARTICULAR FRACTURES OF THE DISTAL RADIUS IN THE ELDERLY PATIENTS

Twenty-eight patients older than 70 years with AO type C fracture of the distal radius were treated with arthroscopically assisted reduction combined with volar plating or external fixation. The patients were followed up for an average of 24.9 ± 16.1 months. The average score was 80.1 ± 10.5 according to the modified system of Green and O'Brien. Eight patients had an excellent result, 11 had a good result, seven had a fair result, and two had a poor result. Twenty-three patients were able to return to their previous activities level or occupation without any restriction. On the basis of these results, we concluded that arthroscopically assisted reduction combined with volar plating or external fixation is one of the useful options for the treatment of a displaced intra-articular fracture of the distal radius in elderly patients who are physiologically young or active.

RADIOCARPAL ARTHRODESIS FOR OSTEOARTHRITIS FOLLOWING FRACTURES OF THE DISTAL RADIUS

To compare the radioscapholunate (RSL) arthrodesis and radiolunate (RL) arthrodesis as a treatment for radiocarpal osteoarthritis following fractures of the distal radius, nine patients, 23 to 70 years old (average 41) at the time of surgery, were assessed two to 33 years after surgery. The periods between injury and surgery ranged from four months to 30 years. RSL arthrodesis was performed in three cases and RL arthrodesis in six. Post-operative wrist pain disappeared in six and was decreased in the other three. In the RSL group, the total arc of wrist flexion and extension was reduced from 50° pre-operatively to 35° post-operatively. In the RL group, it was increased from 72° to 76° after surgery. Grip strength improved in most patients, from 7 to 18 kg in the RSL group, and from 16 to 27 kg in the RL group. On roentogenogram, three patients showed arthritic changes in the adjacent joints, but there were no symptoms in two of the three patients. We concluded that partial radiocarpal arthrodesis (preferably RL arthrodesis) is a reliable procedure for radiocarpal osteoarthritis following fractures of the distal radius.

Treatment for carpal tunnel syndrome by coronal Z-type lengthening of the transverse carpal ligament

OBJECTIVE

To compare the effects of coronal Z-type lengthening of transverse carpal ligament with conventional open approach for carpal tunnel syndrome.

METHODS

A double-blinded study was conducted from January 2005 to August 2008 on 68 patients with a mean age of 41 years (range 27-55 years) diagnosed as severe carpal tunnel syndrome. They were randomized into two groups(A and B). Patients in group A underwent coronal Z-type lengthening of transverse carpal ligament; and patients in group B had conventional open approach surgery. Postoperative evaluation was scheduled at 1, 3, 6 and 12 months after the surgery and incidence rate of bowstring of the flexor tendons, improvement of grip strength and ADL activities of daily living) score were recorded.

RESULTS

Fifty-eight patients had been followed up successfully, 30 and 28 for group A and B respectively. The Scar Tissue Formation of the flexor tendons in group B was observed more than that in group A at 6 and 12 month after operation. Improvement of grip strength were observed in two groups, which was statistically different between 6 and 12 months after operation and no significant difference was seen between 1 and 3 months after operation. According to ADL, the satisfaction rates documented on form for patients were statistically different in the two groups at 6 and 12 months after operation and no difference was noted at 1 and 3 months after operation.

CONCLUSION

Excellent improvement of function and satisfaction were achieved by Coronal Z-type reconstruction of the flexor retinaculum for severe carpal tunnel syndrome. Our method offers a more effective alternative method for conventional carpal tunnel open decompression surgery.

Correlation of awareness and practice of working postures with prevalence of musculoskeletal disorders among dental professionals

Over the last 20 years, a great many innovations have been introduced that are designed to reduce laborious activities; however, an unexpected consequence of these developments is a trend toward a sedentary lifestyle and prolonged static postures that are accompanied by musculoskeletal disorders (MSDs). MSDs have become a major issue of concern because the afflictions can be severe enough to disable professional careers. Although clinical dentistry is a field with immense potential for MSDs, only a few studies have investigated this issue. The present study was carried out addressing prevalence and awareness level of MSDs among 500 dental professionals from Central India. Also, the interrelationship between practices of working postures with occurrence of pain in different body parts were assessed using a structured questionnaire format. The results were statistically significant, and indicated that the prevalence of MSDs is high and that there is a dire need to enhance awareness regarding correct working postures. This study encompassed all factors that can be addressed as causes for MSDs among dentists.

[Analysis of therapeutic effects of external fixator for the treatment of comminuted fracture of distal radius]

OBJECTIVE

To evaluate the clinical effects of external fixator in treating comminuted fracture of distal radius.

METHODS

From Mar.2008 to Dec.2009, 37 patients with comminuted fracture of distal radius were treated with external fixator or assisted with Kirschner wire and T-shape locking compression plate (T-LCP) fixation. There were 14 males and 23 females, ranging in age from 30 to 79 years, with an average of 59.1 years. According to AO typing, type C1 was in 3 cases, type C2 was in 11 cases and type C3 was in 23 cases. Function of wrist joint and X-ray films were observed according to Gratland-Werley system at different months.

RESULTS

All patients were followed up from 8 to 24 months with an average of 12 months. All fractures had healing with an average time of 8 weeks. According to Gratland-Werley system, 16 cases obtained excellent result, 17 good, 4 fair, the rate of excellent and good was 89.0%.

CONCLUSION

External fixator can obtained satisfactory clinical effect in treating comminuted fracture of distal radius.

[Clinical follow-up study of ulnar styloid fractures and classification of distal radial fractures]

OBJECTIVE

To analyze the result of the distal radial fractures with or without ulnar styloid fracture.

METHODS

From January 2007 to October 2010, 62 cases with distal radial fractures were treated by ORIF, of which 52 were followed-up entirely with an average of 15 months (6-34 months), including 6 male cases and 46 female cases at an average age of (62.25±8.25) years. All ulnar styloid fractures were not fixed. According to ulnar styloid fractures, all cases were divided into two groups, group A (32 cases with ulnar styloid fractures) and group B (20 cases without). Group A was further divided into type I (tip fracture of ulnar styloid, 12 cases) and type II (base fracture of ulnar styloid, 20 cases). AO classification, volar tilt, radial inclination and radial height were recorded before and after operation. Complications and Garlant-Werley Scores were evaluated 3 months and 1 year after operation.

RESULTS

All distal radial fractures were union in 8 weeks to 12 weeks. There were significant differences in radial inclination and radial process height, but not in volar tilt between groups A and B before operation. We found no significant differences in volar tilt, radial inclination, radial process height and Garlant-Werley scores between groups A and B 3 months and 1 year after operation. There were also no significant differences between type I and type II. Fineness was 81%. Complications were found in 6 cases (4 in group A and 2 in group B), in which there were 1 case with a screw cutting-off and traumatic arthritis, 2 cases with sup-nerve injury and 1 case with heterotopic ossification, 1 case of malunion , and 1 case with wrist stiffness and traumatic arthritis.

CONCLUSION

ORIF with locking plate in distal radial fracture is safe and effective. There is no significant difference between the outcomes of patients with and without ulnar styloid fractures, also in patients with type I and type II fractures, union or nonunion of fractures, according to the X-ray measurement and Garlant-Werley wrist function scores. However, long-term following-up is still needed.

Plasticity in cortical motor upper-limb representation following stroke and rehabilitation: two longitudinal multi-joint FMRI case-studies

Motor dysfunction and recovery following stroke and rehabilitation are associated with primary motor cortex plasticity. To better track these effects we studied two patients with sub-acute sub-cortical stroke causing hemiparesis, who underwent an effective behavioral treatment termed Constraint Induced Movement Therapy (CIMT). The therapy involves 2 weeks of intensive motor training of the hemiparetic limb coupled with immobilization of the unaffected limb. The study included a longitudinal series of clinical evaluations and fMRI scans, before and after the treatment. The fMRI task included wrist, elbow, or ankle movements. Activity in the M1 upper-limb region of control subjects was stable, strictly contralateral, and similar in amplitude for elbow and wrist movements. These findings reflect the well-known contralateral motor control and support the idea of overlapping representations of adjacent joints in M1. In both patients, pre-CIMT activation patterns in M1 were tested twice and did not change significantly, were contralateral, and included elbow-wrist differences. Following CIMT, the clinical condition of both patients improved and three fMRI-explored prototypes were found: First, cluster position remained constant; Second, ipsilateral activity appeared in the unaffected hemispheres during hemiparetic movements; Third, patient-specific elbow-wrist inter and intra hemispheric differences were modified. All effects were long-lasting. We suggest that overlapping representations of adjacent joints contributed to the cortical plasticity observed following CIMT. Our findings should be confirmed by studying larger groups of homogeneous patients. Nevertheless, this study introduces multi-joint imaging studies and shows that it is both possible and valuable to carry it out in stroke patients.

Impairment of gradual muscle adjustment during wrist circumduction in Parkinson's disease

Purposeful movements are attained by gradually adjusted activity of opposite muscles, or synergists. This requires a motor system that adequately modulates initiation and inhibition of movement and selectively activates the appropriate muscles. In patients with Parkinson's disease (PD) initiation and inhibition of movements are impaired which may manifest itself in e.g. difficulty to start and stop walking. At single-joint level, impaired movement initiation is further accompanied by insufficient inhibition of antagonist muscle activity. As the motor symptoms in PD primarily result from cerebral dysfunction, quantitative investigation of gradually adjusted muscle activity during execution of purposeful movement is a first step to gain more insight in the link between impaired modulation of initiation and inhibition at the levels of (i) cerebrally coded task performance and (ii) final execution by the musculoskeletal system. To that end, the present study investigated changes in gradual adjustment of muscle synergists using a manipulandum that enabled standardized smooth movement by continuous wrist circumduction. Differences between PD patients (N = 15, off-medication) and healthy subjects (N = 16) concerning the relation between muscle activity and movement performance in these groups were assessed using kinematic and electromyographic (EMG) recordings. The variability in the extent to which a particular muscle was active during wrist circumduction--defined as muscle activity differentiation--was quantified by EMG. We demonstrated that more differentiated muscle activity indeed correlated positively with improved movement performance, i.e. higher movement speed and increased smoothness of movement. Additionally, patients employed a less differentiated muscle activity pattern than healthy subjects. These specific changes during wrist circumduction imply that patients have a decreased ability to gradually adjust muscles causing a decline in movement performance. We propose that less differentiated muscle use in PD patients reflects impaired control of modulated initiation and inhibition due to decreased ability to selectively and jointly activate muscles.

The arthritic wrist. II--the degenerative wrist: indications for different surgical treatments

For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined.

Current concepts in the management of the rheumatoid hand

Hand surgeons are an integral part of the management team for patients with rheumatoid arthritis. There is now a greater understanding of the national use of rheumatoid hand surgery, which highlights the differences between hand surgeons and rheumatologists regarding the treatment of the rheumatoid hand. Advances in medical treatments have also decreased the prevalence of hand deformities caused by this disease. Hand surgeons today have less exposure to treating rheumatoid hand, but despite more effective medical options, surgery may still offer patients hope for improvement of hand function and appearance. This article summarizes the current state of rheumatoid hand surgery and discuss the surgical treatment strategies for optimizing outcomes for patients with rheumatoid arthritis.

The reliability of upper limb kinematics in children with hemiplegic cerebral palsy

This study describes the reliability of a protocol for upper limb three-dimensional movement analysis (UL-3DMA) in children with hemiplegic cerebral palsy (HCP). The UL-3DMA is based on the ISB-recommendations, and contains a set of functional and clinically relevant tasks. Tasks were selected to reflect the characteristic movement deficits seen in children with HCP. The protocol consists of three reach tasks (forwards, upwards, sideways); two reach-to-grasp tasks (with objects requiring different hand orientations); and three gross motor tasks. Within and between session reliability was tested in a group of 12 children with HCP, aged 6-15 years. Reliability of movement duration/speed and joint angles at endpoint was assessed with the intraclass correlation coefficient; similarity of the waveforms with the coefficient of multiple correlation. Measurement errors were calculated for all parameters. Results indicated good within and between session reliability for movement duration/speed. Trunk, scapula, shoulder, elbow and wrist angles at endpoint generally showed moderately high to very high reliability. High levels of reliability were also found for scapula, shoulder and elbow waveforms and lower levels for the wrist and trunk. Within and between session measurement errors were below 5° and 7°, respectively, for most kinematic parameters. Joint angles in the transverse plane, as well as wrist flexion generally showed higher between session errors (7-10°). This study indicates that the proposed protocol is a reliable tool to quantify upper limb movements in children with HCP, providing a sound base for its clinical application. Further research is needed to establish the discriminative ability of the UL-3DMA.

Chronic scapholunate dissociation: ligament reconstruction combining a new extensor carpi radialis longus tenodesis and a dorsal intercarpal ligament capsulodesis

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.

Arthroscopic core decompression of the lunate in early stage Kienbock disease of the lunate

Since the first description of Kienbock disease in 1910, the etiology and treatment have remained controversial topics. Core decompression is an accepted treatment option in early-stage avascular necrosis of the femoral head, and more recently the humeral head. This paper reports the technique of arthroscopic fluoroscopically guided core decompression of the lunate with 6-year results.

Capitate pyrocarbon prosthesis in radiocarpal osteoarthritis

Scapholunate dissociation or scaphoid pseudarthrosis may lead to osteoarthritis of the wrist. When osteoarthritis affects the midcarpal joint, proximal row carpectomy is no longer possible and only 4 corners fusion or capitolunate arthrodesis may be indicated. However, in some cases, osteoarthritis or bone necrosis may involve the lunatum, making partial arthrodeses impossible. Total arthrodesis may be proposed in such cases, but with a loss of range-of-motion. Total prosthesis may be considered but the results of this procedure are not always encouraging. Consequently, in these situations, we perform pyrocarbon prosthesis implant, replacing the head of the capitatum. This article describes the procedure and the results of a preliminary study.

Radial osteotomy for Kienböck disease

Of various surgical treatments, radial shortening for patients with negative ulnar variance and radial wedge osteotomy (radial closing osteotomy) for patients with 0 or positive ulnar variance are widely accepted for the treatment of Kienböck disease. Long-term follow-up studies have shown more than 10 years lasting satisfactory pain relief, as well as an increase in wrist range of motion and grip strength. As representative surgical procedures, the techniques of radial shortening by transverse osteotomy, using a locking compression plate for internal fixation, and radial wedge osteotomy by step-cut osteotomy, using a small dynamic compression plate or locking compression plate, are described. One important point of radial wedge osteotomy is that resection of simple wedge bone yields a decrease in ulnar variance; therefore, we recommend trapezoidal bone resection with ulnar height of 1 mm for transverse osteotomy at the metaphysis and ulnar height of 2 mm for step-cut osteotomy at the distal fourth of the radius.

Long term results of matched hemiresection interposition arthroplasty for DRUJ arthritis in rheumatoid patients

INTRODUCTION

The distal radioulnar joint (DRUJ) is commonly affected in rheumatoid arthritis and is associated with significant functional morbidity. The aim of our study is to review our results with matched hemi-resection interposition arthroplasty in patients with DRUJ arthritis.

METHODS

This was a retrospective study of 39 patients with 51 wrists that were treated at Queen Mary Hospital in Hong Kong from 1989 to 2007. All patients underwent matched hemi-resection interposition arthroplasty and dorsal wrist synovectomy. Long arm hinged elbow brace was used for three weeks followed by intensive rehabilitation up to twelve weeks. The indicators of outcome included range of motion assessment, pain, wrist stiffness, grip of strength and need for revision assessed during follow-up. Statistical analysis was performed with student t-test.

RESULTS

The average age of patients was 50.5 years (25 to 77 years) and there was a 35:4 female to male ratio. The average follow up was 4.5 years ranging from 1 to 18 years. Associated extensor tendon ruptures were found in 31.4% patients. The average increase in supination was from 73 degrees preoperatively to 81 degrees at long term follow up (p = 0.10 at 1 year and 0.13 at long term follow-up). The average increase in pronation was from 68 degrees preoperatively to 74 degrees on long term follow up (p = 0.57 at 1 year and 0.02 at long term follow-up). There was evidence of painless, relatively stiff but functional wrist in 37.25% of patients. There was an increase in grip strength from an average of 6.1 kilogram force preoperatively to an average of 11.5 kilogram force at follow-up (p = 0.004 at 1 year and 0.15 at long term follow-up). Complete relief of ulnar sided pain was seen in 43 wrists (84%), partial relief was seen in 7 wrists (13.7%) and no relief was found in one wrist (1.9%).

CONCLUSIONS

DRUJ arthroplasty is a rewarding procedure and most of the patients obtain pain free movement.