Double plate fixation for correction of the malunited distal ulna fracture: a case report

A 62-year-old woman visited our hospital one year after a motor vehicle accident complaining of ulnar wrist pain and restricted pronation and supination. Radiographs showed a 35° angular deformity at the ulnar neck. Closing wedge osteotomy was performed using two plates for stabilization. Twenty-four months postoperatively, the osteotomy site united without correction loss and the patient gained adequate pronation and supination. To the best of our knowledge, this represents the first report of corrective osteotomy for the treatment of malunited ulnar neck fracture. Although salvage operations such as ulnar head resection and the Sauvé-Kapandji procedure may provide reasonable results, anatomical repair can be considered as an option.

Remodeling of distal ulna after excision arthroplasty for acute comminuted distal ulnar fracture: a case report

Bone adaptation after excision arthroplasty of distal radioulnar joint in an acute traumatic distal ulna fracture has never been reported. A case of irreparable and comminuted distal ulnar head fracture was managed by excising the ulna head and repairing the fovea (deep ligament) attachments of distal radioulnar ligaments, and then an unexpected remodeling of the distal ulna with the shape of pole and seat was noted. The anatomy of deep fibers of distal radioulnar ligament is important not only in biomechanics about the stability of distal radioulnar joint but it is also possible in the morphology about the shape of the distal radioulnar joint.

Non-union of an undisplaced radial styloid fracture in a heavy smoker: revisiting the association of smoking and bone healing

Isolated radial styloid fractures occur relatively infrequently, with non-union of such fractures, especially when undisplaced, being highly unusual. Smoking of tobacco, a common habit which is decreasing in prevalence in the developed world, has been proven to exert many adverse effects on tissue healing including bone union. We present a case of non-union of an undisplaced radial styloid fracture in the dominant hand of a young and healthy heavy smoker, emphasising the negative impact of tobacco smoke and its association with bone repair. We suggest that heavy tobacco users should also be followed up more vigilantly with this complication in mind, with smoking cessation modalities being offered on presentation.

Outcome evaluation in patients with distal radius fracture

INTRODUCTION

There are not enough scientific papers on the outcome of distal radius fractures evaluated by the patients themselves. There is disagreement over the degree of correlation between the radiological and functional outcome and the disability of the patients.

AIM

To analyse the correlation between the patient-rated outcome (disability) and radiological parameters of distal radius fractures, as well as the objective parameters of the wrist function (range of motion and grip strength)

MATERIAL AND METHODS

This is a prospective randomized study of 64 patients with a distal radius fracture. To evaluate the disability a patient-rated wrist evaluation (PRWE) questionnaire was used. For radiographic assessment radial length, radial angle and dorsal angle were measured and graded according the Lidstrom method as modified by Sarmiento. The objective clinical parameters evaluated in this study are grip strength and range of movements. For a description of the association between these three outcome parameters a statistical correlation with the Spearman rank correlation was performed.

RESULTS

The results of this study showed no significant correlation between the radiological outcome or the range of motion in the injured wrist with the PRWE pain and disability. Only the grip strength was a significant pain and disability predictor three and six months after injury.

CONCLUSION

Post-fracture rehabilitation and outcome assessment should extend beyond physical impairment and radiography to insure comprehensive treatment to individuals with a distal radius fracture.

The management of chronic distal radioulnar instability

The stabilizing constraints of the distal radioulnar joint (DRUJ) include its bony geometry and the surrounding soft tissue support. Given the shallow nature of the sigmoid notch, reconstruction of the palmar and dorsal ligamentous sleeve provides the best solution for restoring stability in cases of chronic DRUJ instability. The pertinent anatomy, indications, contraindications, soft tissue stabilizing procedures, and rehabilitation for the management of chronic DRUJ instability are highlighted in this review.

Salvage of failed distal radioulnar joint reconstruction

In the patient in whom primary distal radioulnar joint surgery has failed, consideration must be given to the anatomy and biomechanics of the native joint; how this has been disrupted by injury, disease, and previous trauma; and what is required to reconstruct the joint. The forearm relies on a congruent condylar cam of the distal ulna, with intact soft tissue restraints for normal biomechanics. Surgical reconstruction using tendon graft, autologous bone graft, allograft interposition, and prosthetic reconstruction are discussed in this article. If these procedures fail, then salvage procedures including wide excision of the ulna or one-bone forearm can be performed.

Comparison of headless screws used in the treatment of proximal nonunion of scaphoid bone

Screws with different levels of compression force are available for scaphoid fixation and it is known that the Acutrak screw generates greater compression than the Herbert screw. We retrospectively compared two types of headless compression screw for their effectiveness in the repair of scaphoid nonunion. Twenty-nine cases of proximal scaphoid nonunion were surgically treated with non-vascularised bone graft: the Acutrak screw was used in 17 patients and the cannulated Herbert screw in 12 patients. Wrist range of motion, Mayo wrist score, grip strength and QuickDASH scores were indicators used for the functional evaluation. Radiographic findings were assessed for consolidation of nonunion and signs of arthrosis. The mean follow-up time was 49.2 months (range 12-96). Statistically, there was no significant difference between the Acutrak and Herbert screw types in terms of functional evaluation and time required for consolidation. Greater compression did not influence the functional outcome, consolidation rate or time to consolidation. The need for greater compression in the treatment of proximal scaphoid nonunions is thus questionable because it may increase the risk of proximal fragment communition.

The effect of provocative tests on electrodiagnosis criteria in clinical carpal tunnel syndrome

INTRODUCTION & OBJECTIVE

Nerve conduction study is the most sensitive test for diagnosis of carpal tunnel syndrome (CTS). This test is normal in some patients with mild CTS. Median nerve conduction study evaluation after a provocative test (e.g. wrist flexion) may be helpful for diagnosis of mild CTS. This study aimed to determine the effect of wrist flexion on median nerve conduction in patients suspected to CTS and in healthy subjects.

MATERIALS & METHODS

In this case-control study, 20 patients (20 hands) with clinical signs of CTS and normal routine electrodiagnosis test results and 20 healthy subjects were investigated. Measured parameters included: median nerve distal sensory latency (DSL), nerve conduction velocity (NCV) across wrist, compound nerve action potential (CNAP), distal motor latency (DML) and compound muscle action potential amplitude CAMPAMP). The above noted parameters were measured before and after 5 minutes of full wrist flexion. Data were analyzed using paired T-test.

RESULTS

Distal Sensory Latency increment and NCV decrimental after 5 minutes of wrist flexion in the patients group were statistically significant (p > 0.05). The same parameters did not show significant incremental or detrimental changes in the control group.

CONCLUSION

Median nerve DSL and NCV measurement after 5 minutes of wrist flexion may be helpful in determining more sensitive parameters in the electrodiagnosis of CTS.

[Investigation of radioulnocarpal joint load distribution effects of radial shortening osteotomy for the treatment of Kienböck disease: a biomechanical study]

OBJECTIVES

We evaluated the effects of radial shortening osteotomy on the radiolunate joint load distribution.

MATERIALS AND METHODS

This biomechanical study used standard left wrist models made of solid foam (Sawbones, Malmö, Sweden). The radioulnocarpal joint load distribution was investigated in the normal wrist model and 2 mm and 4 mm radial shortening osteotomy models under 14 kgf and 25 kgf loads when the wrist position was neutral.

RESULTS

In the normal wrist group, the comparison of the average pressure distributions under the 14 kgf and 25 kgf loads shows that the increase at the ulnocarpal joint loading and the decrease at the radiolunate joint loading were statistically significant (p=0.012, p=0.036, respectively). When we compared the respective average pressure distributions after 14 kgf and 25 kgf loading, there were no significant differences between the normal wrist and the osteotomy groups.

CONCLUSION

Consequently, radial shortening osteotomy is not effective in decreasing radiolunate joint loading when the wrist is in neutral position.

Update of the physiology and biomechanics of tendon transfer surgery

Tendon transfer surgery has evolved over the past decade. Unique muscle properties have been elucidated in terms of potential force generation, excursion, and metabolic properties. The choice of an appropriate donor muscle is becoming more of a science than an art. The measurement of sarcomere length has progressed from the laboratory into surgery. Methods of tendon coaptation have advanced to allow early mobilization. This article reviews recent advances in our understanding of tendon transfer surgery of the hand and upper extremity.

Scapholunate dissociation with radiolunate arthritis without radioscaphoid arthritis

PURPOSE

Watson and Ballet introduced the concept of a direct association between scapholunate (SL) dissociation and radioscaphoid (RS) arthritis with preservation of the radiolunate (RL) articulation in 1984. This principle has served as the anatomic, biomechanical, and pathophysiological basis for reconstructive surgery in the carpus. Recently, we have noted cases of concurrent SL dissociation and RL arthritis without RS arthritis, which is contrary to the accepted concept of wrist arthritis due to SL advanced collapse. The purpose of this study was to determine whether Watson and Ballet's thesis that SL dissociation results in RS joint degeneration with sparing of the RL joint can be confirmed, or whether another joint degeneration pattern can be associated with SL dissociation.

METHODS

The 3 authors independently reviewed 897 radiographs of the wrist in 691 male patients (206 bilateral and 485 unilateral) with diagnosis codes of wrist osteoarthritis (715.13), wrist instability (718.83), and wrist sprain (842.00). Posterior-anterior, oblique, and lateral views were available for all wrists. Elements assessed were RS joint, RL joint, SL joint, midcarpal joint, ulnar variance, ulnolunate joint, SL angle, and lunocapitate angle.

RESULTS

There were 146 wrists with radiographic SL dissociation. Nine wrists in 6 patients had radiographic SL dissociation and RL arthritis but no RS arthritis. An additional 6 wrists in 6 patients had radiographic RL arthritis but no SL dissociation or RS arthritis; however, 5 of these did have an SL angle of 60 degrees or greater.

CONCLUSIONS

Our results show that RL arthritis can occur in association with SL dissociation, and that the generally held view that the RL articulation is spared in SL advance collapse is not universally true. Consequently, it is our recommendation that both the RL and RS joints should be carefully evaluated for degenerative changes when planning treatment for patients with SL dissociation, because it should not be assumed that the RL joint has been spared.

Complications of wrist arthroplasty

Total wrist arthroplasty is an alternative for patients with severe wrist arthritis who have specific requirements or desires to preserve motion. However, wrist replacement has its own unique risks and potential complications, and is not appropriate for patients with high physical demands. This article discusses these risks and complications and provides strategies to minimize risks and manage complications.

Operative treatment of distal radial fractures with locking plate system-a prospective study

The aim of this study was to determine the results of operative treatment of distal radial fractures with a 2.4-mm locking plate system in a single tertiary teaching hospital. Seventy-five patients were recruited into the study between May 2004 and November 2006. There were 41 males and 34 females, with a mean age of 51. Seventy-five percent of patients had AO type C fractures. All patients were allowed free active mobilisation of the wrist joint immediately after surgery. They were followed up at two weeks, three months, six months, one year and two years. Assessments of pain, motion, grip strength, and standard radiographs were performed. The Gartland and Werley functional scores, the modified Green and O'Brien score, and the disabilities of the arm, shoulder and hand (DASH) scores were recorded. The radiographic results at the final follow-up showed a mean of 18° of radial inclination, 5° of volar tilt, 1.3-mm radial shortening, and no articular incongruity. Twenty-nine percent of patients showed grade 1 osteoarthritic changes and 6% had grade 2 changes in their final follow-up radiographs. An excellent or good result was obtained in 98% and 96% of patients according to the Gartland and Werley, and modified Green and O'Brien scores, respectively. The mean DASH score was 11.6, indicating a high level of patient satisfaction. Internal fixation of distal radial fractures with a 2.4-mm locking plate system provided a stable fixation with good clinical outcomes and patient satisfaction.

[Research on control technology of functional electrical stimulation in wrist movements based on Hammerstein model]

For most of nonlinear systems, control strategy is complicated. The adaptive control methods based on the model identification can effectively improve the control precision and stability. According to the nonlinear and time-changeable characteristics of the wrist movement in the functional electrical stimulation, modeling and identification of wrist movement based on Hammerstein model were implemented. By using M sequence and invert-repeated M sequence as excitation signal, the wrist model is divided into the linear dynamic part and the nonlinear static part. The characteristics of nonlinear part being taken into consideration, an adaptive control method based on time-changeable characteristics of linear part is presented. This method simplifies the control strategy, and it is validated by the simulation experiment of FES.

Locked volar plating for unstable distal radial fractures: clinical and radiological outcomes

We studied 40 patients treated with locked volar plates for unstable distal radial fractures. Outcome was assessed at a mean of 59 weeks, both radiologically and functionally using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, range of motion and grip strength. The complication rate in our series was 48%. In 11 cases, screw penetration into the radiocarpal joint occurred as a consequence of postoperative collapse. Of these, 25% had malunited and 12.5% ruptured their extensor pollicus longus (EPL) tendon. Functionally, when compared with the contralateral side, 74% of extension, 67% of flexion, 91% of pronation and supination and 81% of grip strength were regained. The mean DASH score was 23. Although locked volar plates can achieve good results in the management of unstable distal radial fractures, there remains a high major complication rate. They should be used with caution particularly in fractures with significant metaphyseal comminution.

The treatment of ulnar impaction syndrome: a systematic review of the literature

Ulnar impaction syndrome is a common cause of ulnar-sided wrist pain that is thought to be a result of abutment between the ulna and the ulnar carpus. A systematic review of the literature was conducted to determine the effectiveness of different treatment options in managing ulnar impaction syndrome. PubMed, the Cochrane database, and secondary references were reviewed to identify all English-language articles with reported results on the treatment of ulnar impaction syndrome. A total of 16 articles met the criteria for review. Three procedures were identified as the most commonly used in treating this syndrome: ulnar shortening osteotomy, the wafer procedure, and the arthroscopic wafer procedure. Mean time to union and percentage nonunion for the osteotomy group was 10.3 weeks and 1.7%, respectively. The overall complication rate for patients in the ulnar shortening osteotomy group, the wafer procedure group, and the arthroscopic wafer group was 30%, 8.8%, and 21%, respectively. The authors were unable to determine a single best treatment option based on the available studies, mainly due to the variability in the reporting of subjective outcome measures. Ulnar shortening osteotomy was associated with a higher complication rate than other procedures.

The effect of landmarks and bone motion on posture-related changes in carpal tunnel volume

BACKGROUND

Deviated wrist postures have been linked to carpal tunnel syndrome development, yet the effect of posture on carpal tunnel volume remains unclear. The purposes of this study were (i) to evaluate the effect of boundary definitions on tunnel volume estimates in neutral and non-neutral (30 degrees flexion, 30 degrees extension) wrist postures and (ii) to develop a biomechanical wrist simulation to predict posture-related changes in tunnel volume.

METHODS

Two carpal tunnel volume measures were calculated using (i) ulnar bony landmarks and (ii) radial and ulnar bony landmarks identified directly from magnetic resonance imaging (MRI) scans. A third volume measure combined computerized tunnel reconstructions with modelled bone surfaces to calculate an anatomically landmarked volume. Six individual simulations were then generated to predict volume in the flexed and extended postures based on individual carpal bone motions.

FINDINGS

Boundary definitions influenced the absolute volume in each posture and the relative changes between postures. Relative to fully reconstructed volumes, radial and ulnar landmarked volumes were 15-25% larger across postures (681 (SD 467) mm(3); P=0.01), while the ulnar-only landmarked volumes were 10-20% smaller (562 (343) mm(3); P<0.01). Simulation predicted volumes were not significantly different from the reconstructed anatomically landmarked volumes, with less inter-individual variability between postures compared to MRI-based volumes.

INTERPRETATION

Comparison of volume measures indicated the importance of capturing posture-related changes in the orientation of the proximal and distal tunnel boundaries, and revealed potential sources of error associated with volume reconstruction. Simulations can enable changes in tunnel dimensions to be related to bone movements throughout a range of motion.

[The analysis of prognostic relative factors in patients with type-C fractures of distal radius after internal fixation]

OBJECTIVE

To explore the clinical relative factors on the therapeutic effect of wrist joint function in patients with type-C fractures of distal radius treated with internal fixation.

METHODS

Retrospectively collect consecutive patients of type-C fractures of distal radius treated surgically with open reduction and internal fixation admitted from January 2001 to October 2007. Making Gartland and Werley Score of wrist joint function as the primary outcome variable, the following were assessed: the postoperative efficacy at the follow-up, and use non-conditional Logistic regression to analysis the correlation of wrist joint function with patients' age, gender, time from injury to operation, classifications of type-C fracture, methods of internal fixation and other clinical factors.

RESULTS

In this study, 56 patients met the inclusion were collected. The follow-up time was 3.1 to 29.2 months (mean follow-up 6.3 months). The result of Gartland and Werley Score: 24 patients were excellent, good 26, fair 3, and poor 3; the excellent and good rate was 89.29%. Monovariant and multivariant Logistic regression analysis demonstrated that postoperative efficacy was significantly associated with elder age, time from injury to operation, methods of internal fixation:age (OR = 4.64; 95%CI: 1.48 - 14.54; P = 0.009), time from injury to operation (OR = 9.00; 95%CI: 1.72 - 46.99; P = 0.009), methods of internal fixation (OR = 3.33; 95%CI: 1.10 - 10.12; P = 0.034).

CONCLUSIONS

Elder age (>or= 65 years) and delay of surgery (>or= 13 d) are the influential factors of postoperative functional outcome of distal radius fractures. For the treatment of intra-articular type-C fractures of distal radius, locking compression plate is more effective than T-type plate.

Ulnar head implant arthroplasty: an intermediate term review of 1 surgeon's experience

Ulnar head arthroplasty has been an emerging alternative for salvage of resection arthroplasty at the distal radioulnar joint (DRUJ) since the early 1990s. Recently, it has been offered for initially treating painful arthrosis or instability of the DRUJ. This follow-up study reports a surgeon's experience treating DRUJ disorders with ulnar head arthroplasty. Twenty-two wrists in 20 patients (11 females, 9 males), 6 with no prior wrist procedures were treated between 1995 and 2006 for painful DRUJ disorders with either Herbert-Martin (Martin Medizin-Technik, Tuttingen, Germany) or Avanta (Small Bone Innovations, New York, NY) head prosthesis. Follow-up averaged 54.3 months. A standardized telephone survey determined preoperative /postoperative verbal analog pain scores and a modified Mayo Wrist Score (delineating poor, fair, good, or excellent outcomes). Data suggest that ulnar head implant arthroplasty is a reasonable treatment option for DRUJ-related pain, loss of function, or salvage of failed distal ulna resection procedures. The analog pain score statistically significant decreased by 1.68 points when comparing preoperative to postoperative scores. Average Modified Mayo Wrist Scores were good, independent of whether the procedure was primary or salvaged. No significant difference was seen between the primary or salvage group modified Mayo Wrist Scores. Whereas averaged modified Mayo scores for both the primary and salvage groups were in the good category, prostheses used as primary procedures may be associated with fewer poor or fair outcomes. Two good and 1 excellent outcome of 3 wrists requiring revision procedures suggest that even with revision of the implant arthroplasty, satisfactory results may be expected.

Effect of coexistent scaphotrapezoidal osteoarthrosis on outcome after trapeziectomy

Scaphotrapezoidal osteoarthrosis can cause persistent pain after trapeziectomy. It has previously been recommended that the scaphotrapezoidal joint should be resected at the time of trapeziectomy to avoid this complication if radiographs show evidence of joint degeneration. We have reviewed the records of 77 patients who had 87 trapeziectomies and assessed their radiographs for the presence and degree of osteoarthrosis. There was evidence of scaphotrapezoidal osteoarthrosis in almost half of the hands. Its presence, however, had no influence on subjective or objective measures of pain, function or power before or after operation, or on outcome. Only one patient required resection of the scaphotrapezoidal joint because of persistent pain. Resection of the joint cannot be recommended as a routine adjunct to trapeziectomy on radiological evidence alone.

Outcome of proximal row carpectomy

Fifty-one patients who had had proximal row carpectomy between 1992 and 2002 with a minimum follow-up of one year were followed up clinically and radiologically retrospectively. Their diagnoses included Kienböck disease (n=21), avascular necrosis of the scaphoid (n=4), nonunion of the scaphoid with osteoarthritis (n=9), and scapholunate advanced collapse (n=17). The mean follow-up was 5 years, 8 months. The mean "disabilities of the arm, shoulder and hand" (DASH) score was 18. The mean patient-rated wrist evaluation (PRWE) score list was 25% of maximum disability for the function and pain score. Thirty-four patients (87%) were able to return to work a mean of six months after operation (range 3 weeks - 35 months). Nine patients (11%) required arthrodesis of the wrist and are considered as failures. Mean flexion of the wrist was 66%, extension 73%, radial deviation 74%, ulnar deviation 76%, and grip force 70% of the opposite side. Excision of the proximal row provided predictable and durable pain relief, restored functional movement and grip strength, and allowed returned to gainful employment in most of the patients.

Arthrodesis for chronic static scapholunate dissociation: a prospective study in 12 patients

Twelve patients had limited arthrodesis between the scaphoid and the lunate for chronic static scapholunate dissociation using internal plate osteosynthesis. The median time between the injury and surgery was 50 months (range 9-180). They were followed up for a year postoperatively. Preoperative symptoms were pain, functional impairment, and restricted movement. During operation the scapholunate interosseous ligament was completely torn and the scaphoid malrotated in all patients. The range of motion was measured preoperatively and postoperatively, and the unaffected side used for control. For all patients except one postoperative extension, flexion, and radial deviation had considerably decreased. However, supination increased in seven of 12 patients postoperatively and so did pronation in seven of 12 patients. One patient (case 12) had an improved range of motion postoperatively in all directions. The mean grip strength was 76% of the unaffected side preoperatively, and has increased to 85% postoperatively. We found that bone healing was rare and most arthrodeses healed by a fibrous union. We found no correlation with preoperative arthrosis and clinical outcome. One patient had retired from work before operation because of back pain and one because of age. Two patients had taken early retirement because of wrist pain, and one patient was still on sick-leave at the follow-up a year postoperatively. Five patients returned to full-time work and two patients to part-time work. Four patients were on long-term sick-leave preoperatively and three of them returned to their previous occupations. Analysis of the patients' subjective outcome (including pain and functional scores) showed overall satisfaction, and objective data show that scapholunate arthrodesis for chronic static scapholunate dissociation provides substantial improvement over the preoperative condition.

Upper limb sensorimotor function and functional performance in patients with rheumatoid arthritis

PURPOSE

Although sensorimotor deficits have been identified in isolated upper limb joints of patients with rheumatoid arthritis (RA), relatively little is known about the presence or consequences of sensorimotor deficits in the upper limb as a whole. To address this, we compared sensorimotor and functional performance in multiple upper limb joints of patients with RA and healthy subjects.

METHODS

Global upper limb strength, proprioception (joint position sense) and the time taken to perform 2 common functional daily activities (dressing and eating) were estimated in 31 RA patients and 18 healthy subjects. Disability, pain and clinical disease activity were also assessed in the RA patients.

RESULTS

The RA patients were weaker (mean difference 280N, 95% Confidence Interval 172 to 389; P < 0.001), had poorer functional performance (6 sec, CI 8.1 - 23.9; P < 0.001), hand grip strength (117 mmHg, CI 61 - 173; P < 0.001) and proprioceptive acuity (2 degrees , CI 0.4 - 3.5; P < 0.05) than the healthy subjects. Upper limb functional performance and disability in the RA patients were inversely associated with global upper limb (r = -0.54 to -0.36) and hand grip strength (r = -0.51 to -0.32) but not proprioception (r = 0.55 - 0.11).

CONCLUSIONS

Compared to healthy subjects, patients with RA had global upper limb sensorimotor deficits. Weakness contributes to poor upper limb function and disability in patients with RA, although the clinical importance of proprioception is unclear.

Outcome of four-corner arthrodesis for advanced carpal collapse: circular plate versus traditional techniques

Twenty eight patients with advanced carpal collapse (20 with scapho-lunate advanced collapse [SLAC] and 8 with scaphoid-nonunion advanced collapse [SNAC]) who were treated with a four-corner arthrodesis were reviewed; 23 had a good or excellent outcome. The mean DASH score was 41. The flexion/extension arc decreased from 72 degrees to 52 degrees. Gripping force increased from 46% to 72%. The range of motion was better in those with a traditional fixation (K-wires or screws) compared to the newer circular plates. There was no significant difference concerning pain relief, gripping force and disability.

The effect of elbow joint centre displacement on force generation and neural excitation

Joint centre displacement may occur following total elbow replacement due to aseptic loosening or surgical misalignment, and has been linked to implant failure. In this study, the effects of joint centre displacement were examined using a neuromusculoskeletal model of the elbow joint. Isometric contractions were simulated at a range of joint angles during elbow flexion and extension. Displacement of the joint centre affected the force-generating capacity about the joint, due to changes in both muscle lengths and moment arms. The magnitude and direction of the maximum joint reaction force were also altered, potentially contributing to aseptic loosening and compromising joint stability. The relationship between force generated and the level of neural excitation to the elbow flexor and extensor muscles was also affected, suggesting that altered neural control patterns could be required following joint centre displacement.

[Method of thermographic study of the wrist joints]

The article presents developed technique of assessment of hand thermograms in healthy volunteers and patients with disorders of hand articulations. The authors have also presented analysis of the results of thermography of hands of 94 healthy person. Methods of practical use of obtained data in medicine to diagnose complicated hand articulations were presented.

Chronic volar distal radioulnar joint instability: joint capsular plication to restore function

BACKGROUND

Volar instability of the distal radioulnar joint (DRUJ) is uncommon, and there is little written about it. The purpose of this study is to describe a new procedure to treat volar DRUJ instability and to present the outcomes of patients who received this unique surgical repair at a minimum of 1 year follow-up.

METHODS

We performed a retrospective case series of 6 consecutive patients treated with a volar and dorsal capsular plication procedure by an upper extremity specialist surgeon at a teaching hospital between April 1999 and October 2004. We evaluated measures, including wrist range of motion, grip strength, radiographs, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Patient-Rated Wrist Evaluation (PRWE), at final follow-up.

RESULTS

Five of 6 patients had resolution of pain and instability symptoms. The average difference in range of motion between operative and contralateral sides was -7 degrees flexion, 2 degrees extension, 4 degrees radial deviation, 2 degrees ulnar deviation, -17 degrees supination and -2 degrees pronation. Average grip strength measured 83% of the uninjured side. The average DASH score was 13.5 (range 0-46.7), and the average PRWE score was 26.7 (range 0-70). One patient had a low ulnar neuropathy, which resolved. One patient fractured the temporary DRUJ stabilization screw and had radiographic evidence of nonbridging heterotopic ossification.

CONCLUSION

Joint capsular plication for DRUJ has not yet been described in the literature. It is less elaborate in that it does not require a tendon graft with bone tunnels. The results at an average 16.5 months postoperatively are promising.

Comparison of the "contact biomechanics" of the intact and proximal row carpectomy wrist

PURPOSE

The proximal row carpectomy (PRC) is a clinically useful motion-preserving procedure for various arthritides of the wrist. However, there are few studies on the "contact biomechanics" after PRC. The purpose of this study is to evaluate the contact biomechanics in terms of pressure, area, and contact location of the intact and PRC wrist.

METHODS

Six fresh-frozen cadaver forearms were tested in neutral, 45 degrees of flexion, and 45 degrees of extension. In the intact wrist, Fuji UltraSuperLow pressure contact film was placed in the radioulnocarpal joint. The specimen was loaded to a total force of 200 N. We then performed a PRC, and the experiment was repeated using Fuji Low film. The film was scanned and analyzed with a customized MATLAB program. Multivariable analysis of variance with multiple contrast testing and Student's t-test were performed for statistics.

RESULTS

In the intact wrist, scaphoid contact pressure averaged 1.4 megapascals (MPa), and lunate contact pressure averaged 1.3 MPa. In terms of contact location, scaphoid contact in the intact wrist significantly moved dorsal and ulnar in flexion and significantly moved volar and radial in extension. Lunate contact significantly moved dorsal in flexion. PRC wrist contact pressure was 3.8 times that of the intact wrist, and the contact area was approximately 26% that of the intact wrist. Lastly, in terms of the amount of contact translation after PRC, the capitate contact translated (7.5 mm) more than did the scaphoid contact (5.6 mm) and had about equal translation to that of the lunate (7.3 mm).

CONCLUSIONS

Contact pressure increased significantly and contact area decreased significantly after PRC. There is significant contact translation after PRC (more than scaphoid translation but equal to lunate translation), which provides quantitative support of the theory that translational motion of the PRC may explain its good clinical outcomes.

Pre- and postoperative Guyon's canal pressure change in endoscopic carpal tunnel release: correlation with transient postoperative Guyon's canal syndrome

Perioperative Guyon's canal and carpal canal pressure in one-forearm portal endoscopic carpal tunnel release surgery were measured in resting position and during active power gripping in 66 hands. This was done using the continuous infusion technique with a local anaesthetic and without pneumatic tourniquet. Immediate mean postoperative Guyon's canal and carpal canal pressure decreased in both measurements. During active power gripping, postoperative Guyon's canal pressure was less than 40 mmHg in 61 hands, however, this increased to over 40 mmHg in five hands. In these five hands, Guyon's canal syndrome did not develop. Guyon's canal and carpal canal pressures were only correlated during postoperative active power gripping. It remains unclear whether immediate postoperative Guyon's canal pressure correlates with higher pressures a few days later as reported in cases of transient postoperative Guyon's canal syndrome.

The distal radioulnar joint

The distal radioulnar joint (DRUJ) acts in concert with the proximal radioulnar joint to control forearm rotation. The DRUJ is stabilized by the triangular fibrocartilage complex (TFCC). This complex of fibrocartilage and ligaments support the joint through its arc of rotation, as well as provide a smooth surface for the ulnar side of the carpus. TFCC and DRUJ injuries are part of the common pattern of injuries we see with distal radius fractures. While much attention has been paid to the treatment of the distal radius fractures, many of the poor outcomes are due to untreated or unrecognized injuries to the DRUJ and its components.

Temporary scaphotrapezoidal joint fixation for adolescent Kienböck's disease

PURPOSE

There are few therapeutic guidelines for adolescent Kienböck's disease. The purpose of our study was to investigate the clinical and radiographic outcomes of temporary scaphotrapezoidal (ST) joint fixation for adolescent Kienböck's disease.

METHODS

This was a retrospective review of 6 adolescent patients with Kienböck's disease treated by temporary ST joint fixation. All patients had pain with rest and activity before surgery. The mean patient age at the time of surgery was 14 years, and final follow-up examination was at a mean of 23 months. Under general anesthesia, 2 or 3 K-wires were inserted from the dorsal trapezoid to the scaphoid. The wires were removed at 3 to 6 months.

RESULTS

Mean postoperative wrist extension and flexion were increased from 46 degrees and 48 degrees to 68 degrees and 77 degrees , respectively. These improvements were statistically significant compared with preoperative wrist extension and flexion. Grip strength significantly increased from 52% to 86% of the unaffected side. None of the 6 patients had postoperative pain either at rest or with activity. On final follow-up wrist x-ray films, none of the patients had sclerotic change or fragmentation of the lunate, although decreased lunate height remained in all patients. Magnetic resonance imaging revealed improvement to nearly normal intensity of the lunate on T1- and T2-weighted images in all patients.

CONCLUSIONS

Both clinical and radiographic outcomes of temporary ST joint fixation for adolescent Kienböck's disease were excellent. We therefore recommend this procedure for the surgical treatment of adolescent Kienböck's disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears

PURPOSE

The objective of this retrospective study was to determine functional and subjective outcomes of patients with Palmer type 1B tears repaired arthroscopically and to investigate whether clinical outcomes are related to ulna length.

METHODS

Forty-six patients with arthroscopic repair of Palmer type 1B tears were reviewed. There were 23 males and 23 females. The average age was 34 years (range, 10 to 58 yrs). The average follow-up was 11 months (range, 6 to 23 mos), and the delay to surgery was 9.7 months. All patients suffered ulnar-sided wrist pain and were diagnosed with Palmer type 1B tears. The tear was repaired arthroscopically with an inside-outside suture technique. The range of motion (ROM), grip strength, pain, wrist score (modified Mayo wrist score), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) score, and ulna length (static and dynamic) were evaluated.

RESULTS

There was a reduction in pain and an improvement in grip strength. Postoperative ROM averaged 128 degrees +/- 23 degrees for the extension/flexion arc, 41 degrees +/- 11 degrees for the radial/ulnar deviation arc, and 171 degrees +/- 19 degrees for the pronation/supination arc of motion. However, no relation could be found between ulna length and clinical outcome. The modified Mayo wrist score was rated excellent in 22% of patients, good in 41%, fair in 27%, and poor in 10%. The average DASH score was 21.70 +/- 17.17 (range, 0 to 58.33).

CONCLUSIONS

Arthroscopic repair of Palmer type 1B tears yields satisfactory results. Sixty-three percent of patients achieved good to excellent results, experienced increased ROM, grip strength, and pain relief. Ulnar neutral or positive variance is not a contraindication for suture repair and does not require simultaneous ulna shortening when repairing the triangular fibrocartilage complex arthroscopically. A delay to surgery did not affect clinical outcome.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The patient-rated wrist evaluation (PRWE): cross-cultural adaptation into German and evaluation of its psychometric properties

OBJECTIVE

To cross-culturally adapt the Patient-Rated Wrist Evaluation form (PRWE) into German (PRWE-G) and to evaluate its reliability and validity.

METHODS

A cross-cultural adaptation of the PRWE was carried out, according to established guidelines. 103 patients, who had undergone resection interposition arthroplasty (RIAP) for carpometacarpal osteoarthritis approximately 6.2 years earlier, completed a questionnaire booklet containing the PRWE-G, the Short Form 36 (SF-36), the Disabilities of Arm, Shoulder, and Hand (DASH); they also underwent clinical assessment with the Hand Function Index (HFI, Keitel) and Custom Score including grip and pinch strength tests. The results were used to assess the criterion and construct validity of the PRWE-G. To measure the re-test reliability, 51 patients completed a second PRWE-G within 2 weeks.

RESULTS

The test-retest reliability of the PRWE-G was acceptable for the pain and function sub-scales and for the global score, with intraclass correlation coefficients of 0.78-0.87. The PRWE-G showed a high internal consistency (Cronbach's alphas of 0.92-0.97 for the scales and the total score). The typical error of measurement for the global score was 8.1 points, giving a minimal detectable change (MDC<inf>95%</inf>) of approximately 22.5 points. The PRWE-G scores correlated well with those of the DASH (r=0.82, p<0.001) but less well with those of the physical component summary of the SF-36 (r=0.53, p<0.001) and not at all with the mental component summary scores of the SF-36 (r=0.04, p>0.05). The PRWE-G scores correlated moderately with certain clinical findings of the HFI, Custom Score, and grip/pinch strength tests (r=0.30-0.59, p<0.001).

CONCLUSION

The PRWE-G represents a valid and reliable instrument to evaluate self-rated outcome in German-speaking patients with hand and wrist pathology.

Implant arthroplasty for the distal radioulnar joint

The distal radioulnar joint (DRUJ) is a weight-bearing joint; the ulnar head is frequently excised either totally or partially and in some cases is fused because of degenerative, rheumatoid, or posttraumatic arthritis and treated with a "salvage procedure." The result of these procedures is the inability of those patients to lift even minor weight. Articles about these procedures report the ability to pronate and supinate, but they rarely discuss grip strength or lifting capacity. We present an alternative to the salvage procedures that allows full range of motions as well as the ability to grip and lift weights encountered in daily living, such as a gallon of milk. The Aptis total DRUJ replacement prosthesis (Aptis Medical, Louisville, KY), a bipolar self-stabilizing DRUJ endoprosthesis, restores the forearm function. The technique of implantation is presented here.

Median nerve excursion in response to wrist movement after endoscopic and open carpal tunnel release

PURPOSE

To compare the perioperative kinematic effects of endoscopic versus open carpal tunnel release on longitudinal excursion (gliding) and volar displacement (bowstringing) of the median nerve at the wrist region in patients with idiopathic primary carpal tunnel syndrome.

METHODS

Sixteen hands of 13 patients were randomly assigned into 2 groups (group 1, endoscopic; group 2, open carpal tunnel release). For the measurement of gliding and bowstringing of the median nerve, a metallic marker was used. Before and after the division of the transverse carpal ligament, longitudinal excursion and volar displacement of the median nerve were calculated based on fluoroscopic imaging for each wrist. Movement was analyzed for the measurement of the marker locations.

RESULTS

The mean prerelease median nerve excursion during wrist range of motion was 20 mm (range, 10-28) in group 1 and 21 mm (range, 16-31 mm) in group 2. The mean postrelease median nerve excursion during wrist range of motion was 20 mm (range, 13-29) in group 1 and 18 mm (range, 8-26 mm) in group 2. There was no statistically significant difference in pre- and postrelease longitudinal excursion changes between the groups (p = .916 and p = .674, respectively). The mean prerelease volar displacement of the median nerve during wrist range of motion was 3 mm in group 1 and 4 mm in group 2; the postrelease mean values were 2 mm and 5 mm, respectively. There was no statistically significant difference between the groups with regard to pre- and postrelease volar displacement changes of the median nerve (p = .372 and p = .103, respectively).

CONCLUSIONS

This study demonstrated that the endoscopic release and open carpal tunnel release produce similar perioperative effects on longitudinal and volar movements of the median nerve.

[Wrist stability after experimental traumatic triangular fibrocartilage complex lesions]

OBJECTIVE

To evaluate the changes in stability of the wrist after experimental traumatic triangular fibrocartilage complex (TFCC) lesions, and to provide basic theoretical criteria for clinical treatment.

METHODS

Fourteen adult cadaver upper extremities specimens were included. Two of 14 specimens were tested in pre-experiment. The specimens were tested in a INSTRON 8874 biomechanics measuring instrument. First a dorsal arthrotomy (ART) was performed, and second test was with 1 of 4 different experimental lesions according to Palmer's classification of traumatic TFCC lesions (n=3). 1A: central perforation; 1B: ulnar avulsion with or without fracture of processus styloideus ulnae; 1C: distal avulsion with ligament injury; 1D: radial avulsion. Forced internal external rotation torque were recorded in the interval -60 degrees to 60 degrees of flexion.

RESULTS

The average torque of the dorsal ART was (0.713 +/- 0.121) Nm, and the 1B-1 lesion (ulnar avulsion without ulnar styloid fracture) was (0.709 +/- 0.134) Nm, the 1B-2 lesion (ulnar avulsion with ulnar styloid fracture) was (0.409 +/- 0.113) Nm. The difference between the 1B-1 lesion and the dorsal ART was not significant but the difference between the 1B-2 lesion and the dorsal ART was significant (P < 0.05). The average torque of the 1C lesion in about 45 degrees of wrist extension and flexion were (0.878 +/- 0.184) Nm and (0.988 +/- 0.197) Nm, and the dorsal ART were (1.510 +/- 0.173) Nm and (1.540 +/- 0.093) Nm. The difference between the two groups was significant (P < 0.05). The 1A lesion and 1D lesion did not alter significantly wrist stability.

CONCLUSION

The 1B-2 lesion and 1C lesion alter significantly the stability of the wrist.

Quantification of wrist joint laxity

PURPOSE

Laxity may be a trigger for chronic unidentified wrist pain. To determine whether this is the case, first an objective method to quantify wrist laxity needs to be defined. This study investigates different quantification methods (reference tests) from the literature and compares these with the judgment of 2 independent experienced clinicians (index test, or gold standard).

METHODS

Fifty healthy women (ages 19-43 y) without wrist complaints were included. For each subject, both clinicians were asked to give a laxity score for both wrists on a Likert scale of 1 to 5 (1 = very stiff, 5 = very lax). Subjects also had 3 reference tests: the Garcia-Elias method (passive range of motion), the Beighton method (general hypermobility), and the active range of motion method (specially designed measurement device).

RESULTS

There was no significant difference between the average laxity scores of clinicians 1 and 2. The intraclass correlation between clinician 1 and clinician 2 was significant but low. Correlation between the clinicians with the Garcia-Elias test as well as the Beighton method was significant but low (0.431 and 0.378). The correlation between reference tests was higher but still moderate.

CONCLUSIONS

This study showed that the index test used (clinical assessment) did not produce a satisfactory quantification of wrist laxity. Also, the reference tests are not suitable for quantification of laxity and seem to measure mobility rather than laxity. To quantify wrist laxity in a reliable and clinically relevant manner, it seems that consensus needs to be established between clinicians as to what elements of (abnormal) wrist motion define the wrist as "lax." In addition the development and testing of a measurement device that quantifies wrist translation might be needed for determining an objective score for wrist laxity.

[Treatment of old scaphoid fracture with absorbable screw]

OBJECTIVE

To explore a new approach to treat old scaphoid fracture by grafting bones from distal radius and fixing absorbable screws.

METHODS

From January 2002 to May 2007, 18 patients with old scaphoid fractures were treated by grafting bones from distal radius and fixing absorbable screws. All of the 18 patients (13 males and 5 females, aged from 17 to 41 years old) had the injury history of the palm of hand touching the ground. They felt tenderness on the anatomical snuff-box and tubercle of scaphoid bone. The grasping force decreased. The range of motion of the wrist was (36 +/- 2) degrees extension/(30 +/- 3) degrees flexion, (8 +/- 3) degrees radialis/(13 +/- 2) degrees ulnaris.

RESULTS

The average postoperative follow-up period was 15.7 months. A total of 18 cases achieved bone union. The range of motion of the wrist in the 16 healed cases was (68 +/- 2) degrees extension/(65 +/- 3) degrees flexion, (15 +/- 3) degrees radialis/(28 +/- 5) degrees ulnaris. There was no pain of motion and symptom of powerlessness. As to the other 2 cases, the range of motion of the wrist was (40 +/- 8) degrees extension/(35 +/- 6) degrees flexion, (8 +/- 5) degrees radialis/(12 +/- 5) degrees ulnaris; no obvious improvement was found; the patients occasionally felt painful in daily life; the extension force decreased. No infection and break of internal fixation were seen.

CONCLUSION

The absorbable screw as a new biomaterial for internal fixation has obvious advantages of good biocompatibility, promoting union of the fracture and no need of a second operation for removal.

Segmental radius and ulna fractures with scaphocapitate fractures and bilateral multiple epiphyseal fractures

Segmental forearm fractures are rare in children, and management is controversial. Epiphyseal injuries further complicate matters. We report the case of a 15-year-old boy who had segmental radius and ulna fractures with a coronal split of a metaphyseal fragment, along with bilateral epiphyseal fractures of the distal radius and ulna as well as ipsilateral scaphocapitate fractures with perilunate dislocation. There was also a contralateral fracture through the radial neck. The patient underwent immediate internal fixation of the forearm fractures and delayed fixation of the scaphocapitate fractures. Results at 12 months showed excellent functional outcome.

The incidence of dorsal radiocarpal ligament tears in patients having diagnostic wrist arthroscopy for wrist pain

PURPOSE

The goal of this study was to examine the incidence of dorsal radiocarpal ligament (DRCL) tears in patients having diagnostic arthroscopy for chronic wrist pain.

METHODS

A chart review was performed of 64 patients who had diagnostic wrist arthroscopy for chronic wrist pain that was refractory to conservative measures. For each case, interosseous ligament instability/tears were graded according to the Geissler classification. Tears of the triangular fibrocartilage complex and the presence or absence of a DRCL tear were noted.

RESULTS

There were 35 of 64 wrists (in 64 patients) with DRCL tears. The average duration of wrist pain prior to treatment was 20 months. Only 10 patients could recall a specific injury. Five patients had an isolated DRCL tear. A scapholunate interosseous ligament injury was identified in 13 patients, of whom 7 had a concomitant DRCL tear. A lunotriquetral interosseous ligament injury was present in 7 patients, of whom 2 had a concomitant DRCL tear. Two patients had a capitohamate ligament tear: 1 of these patients had a DRCL tear. There were 7 patients with a solitary triangular fibrocartilage complex tear: 6 of 7 were in association with a DRCL tear. One patient had a chronic ulnar styloid nonunion and a DRCL tear. Two or more lesions were present in 23 patients; DRCL tears were present in 12.

CONCLUSIONS

DRCL tears are commonly seen with injuries to the primary wrist stabilizers. Recognition of this condition and further research into treatment methods are needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Disseminated sporotrichosis presenting with granulomatous inflammatory multiple mononeuropathies

We describe a case of sporotrichosis that disseminated to involve multiple nerves after initiation of immunosuppressive therapy and then precipitously worsened after withdrawal of therapy. This case illustrates that multiple mononeuropathies are not always caused by vasculitis, and a correct pathological diagnosis should be established before treatment. Based on clinical and pathological features, the mechanism of neuropathy may have been due to either direct nerve infection or a bystander effect of inflammatory/immune damage or, perhaps more likely, to both mechanisms.