Safe zones in volar portals for wrist arthroscopy, evaluation of central portal : a cadaveric study

The purpose of this cadaveric study is to determine safe zones utilizing volar portals for wrist arthroscopy, by quantitatively describing the neurovascular relationships of a volar radial and a volar ulnar wrist arthroscopy portals in comparison with those of a newly described volar central portal (7) , considering the advantages in visualization of volar portals for wrist arthroscopy over the standard dorsal (19) . The neurovascular structures and the tendons of nine frozen human cadaveric upper limbs were exposed, while the aforementioned volar portal sites were pointed out with pins. The horizontal distance between the portals and the closest neurovascular branch or tendon was measured with a digital caliper, followed by statistical analysis of the data. The median interquartile range distances from portals to structures at risk were measured and safe zones around each portal were established. This study provides a safe approach to the volar radial and ulnar aspects of the radiocarpal and midcarpal joints, while volar radial and ulnar portals should be considered for inclusion in the arthroscopic examination of any patient with radial and ulnar sided wrist pain respectively (17,18) . Regarding the volar central portal, it is reproducible, safe and both the above joints can be inspected through one single incision (7) .

Power-Doppler perfusion phenotype in RA patients is dependent on anti-citrullinated peptide antibody status, not on rheumatoid factor

It is not known whether there are any consistent non-serological differences between seropositive and seronegative rheumatoid arthritis, and if any, whether they depend upon rheumatoid factor (RF), anti-citrullinated peptide antibodies (ACPA), or both. In a pilot study, we showed that the two forms could be differentiated using power-Doppler sonography (PDS), and that the difference is ACPA dependent. This extended study explored whether the previous findings could be confirmed. 103 patients 51 ACPA positive (ACPA +), 52 ACPA negative (ACPA -) with active wrist arthritis were examined using PDS. By means of a temporal image series, pulsatility was evaluated over a 3-5-s period, maximum and minimum perfusion signal were determined using a computer program counting the number of coloured pixels for each frame. Maxima (P_max) and minima (P_min) were determined, and the standardized peak-to-peak amplitude sA was calculated (sA = (P_max - P_min)/P_max). This parameter was then compared for ACPA + and ACPA- patients. In addition, a multivariate regression was performed, to determine which factors influence sA. sA differed significantly between ACPA + and ACPA- patients [20% (13-26) vs. 41% (32-57), p < 0. 0001]. In the multivariate analysis, age (t = 2.5, p = 0.02) and ACPA status (t = - 4.8, p < 0.0001) were independent predictors of sA. PDS perfusion patterns are different in seropositive and seronegative RA. The difference appears to be ACPA, not RF dependent. This suggests that the underlying pathophysiological process is different in ACPA-positive and ACPA-negative RA.

A classification-based treatment algorithm for Kienböck disease: current and future considerations

Kienböck disease is an isolated disorder of the carpal lunate associated with characteristic, and often progressive, clinical and radiographic changes. Appropriate intervention at specific disease stages represents the best opportunity to achieve good outcomes. As understanding of the disease improves, new therapeutic and diagnostic innovations have surfaced that further augment existing treatment options. Biologic, not just traumatic, processes may explain the onset and progression through the disease continuum. In addition to observing the obvious osseous changes, there has been renewed interest in understanding the vascular and cartilaginous manifestations of the disorder. Recognition of these factors can permit focused areas of intervention, including gene and cell-based therapies in the earliest stages. New diagnostic techniques are also being investigated. Advanced imaging modalities can facilitate the earlier recognition of Kienböck disease and enhance the assessment of lunate vascularity. Moreover, diagnostic arthroscopy permits us to directly visualize and characterize affected structures, including cartilage. Finally, there has been much recent interest in the natural history of Kienböck disease. Infantile, juvenile, and geriatric forms have been described. It has been suggested that the disease pathway in these individuals may differ from the typical adult patient population. Integrating these contemporary findings with the classic information on Kienbock disease can permit a more sophisticated approach to stage-specific treatment. This article reexamines the current classification systems to account for these emerging concepts.

Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand.

Distraction osteogenesis for ulnar lengthening in Kienbock's disease

Ulnar lengthening is an accepted modality of treatment to achieve joint levelling in Kienbock's disease. The conventional method of ulnar lengthening with a plate and bone graft is fraught with complications including graft site morbidity, non-union, hardware removal and difficulty in the achievement of a proper length. We used a Umex distractor to achieve distraction osteogenesis in a group of 12 patients and assessed them over an average follow-up period of 29.5 months. We had one excellent, ten good and one fair result. We conclude that distraction osteogenesis addresses all the complications of coventional lengthening in addition to providing an increase in the local blood supply, which might be beneficial in a disease that is primarily an avascular necrosis. This procedure addresses both the biomechanical and the biological aspects of this disease.

Wrist anatomy and surgical approaches

Appreciation and knowledge of anatomy as it relates to surgical approaches is critical for planning treatment of traumatic wrist injuries. This article discusses the pertinent anatomy and some of the more commonly used approaches to wrist trauma.

Three-dimensional Doppler sonographic vascular imaging in regions with increased MR enhancement in inflamed wrists of patients with rheumatoid arthritis

OBJECTIVE

To compare three-dimensional (3D) power Doppler ultrasonography (PDUS) with contrast enhanced magnetic resonance imaging (MRI) in their capability to visualize synovial vascularity in inflamed wrists of patients with rheumatoid arthritis (RA).

METHODS

Nine patients with RA showing clinically active arthritis of the wrist as determined by tenderness and swelling were examined by contrast enhanced MRI and 3D PDUS. Vascularity close to and inside the joint capsule was visualized by conventional power Doppler mode. In a region with high Doppler signal intensity (=region of interest/ROI) a 3D blood vessel tree was obtained by a free-hand sweep. 3D images were evaluated with regard to the number of blood vessels in the intra- and peri-articular region. MRI examinations were performed using a 1.5 T Scanner. In MRI, time resolved coronal contrast enhanced T1-weighted sequences with fat suppression were acquired during an 8 min period to assess tissue enhancement. Relative enhancement was calculated and compared to 3D PDUS findings.

RESULTS

A 3D vascular tree consisting of peri- and intra-articular blood vessels could be demonstrated in the same anatomical ROI in which an increased gadolinium enhancement was measured by MRI in all examined RA patients. The number of penetrating vessels into the joint capsule, the number of intra-articular vessels and a semiquantitative estimation of the strength of blood flow were used to generate a 3D score for the intensity of synovial vascularity.

CONCLUSION

When compared with clinical symptoms and the gold standard dynamic MRI, 3D PDUS is a reliable imaging technique for assessing synovial vascularity in inflamed wrists of RA patients.

Power Doppler assessment of overall disease activity in patients with rheumatoid arthritis

PURPOSE

To examine synovial vascularity and flow patterns in hand and wrist joints--metacarpophalangeal (MCP) joints and ulnar stiloid (USTL) regions--of patients with rheumatoid arthritis (RA) using power Doppler sonography (PDUS) and spectral Doppler analysis and to assess the accuracy of PDUS in detecting overall disease activity in RA patients.

METHODS

Two hundred forty MCP joints and 48 USTL regions in 24 RA patients were examined. Patients were categorized into 2 groups--active and inactive--according to the American College of Rheumatology remission criteria. Resistance indexes (RIs) were measured.

RESULTS

Flow signals were detected in 50 MCP joints (in 13 patients) and 24 USTL regions (in 16 patients) and spectral analysis was performed in 46 MCP joints (12 patients) and 23 USTL regions (16 patients). The sensitivity and specificity of PDUS in detecting disease activity in RA were 92% and 40%, respectively. There was a negative correlation between flow signal number and RI, with higher scores of flow signals corresponding to lower RIs.

CONCLUSION

PDUS appears to be a reliable method for assessing inflammatory activity in rheumatoid synovium.

Superficial brachial artery

Anomalies of the ramification of arteries in the upper extremity are an important consideration due to the large number of invasive procedures, both diagnostic and therapeutic, performed particularly in the cubital region of the upper limb. It is important for health professionals to be aware of arterial variation to prevent complications during diagnostic and therapeutic procedures. Here, we describe a rare unilateral anomaly of the brachial artery which courses subcutaneously through the right arm to the cubital region in a 75 year-old female patient.

Wrist joint involvement in systemic lupus erythematosus. An ultrasonographic study

OBJECTIVE

To define joint alterations in the wrists of patients with systemic lupus erythematosus (SLE) by ultrasonography (US).

METHODS

Fifty-two wrists of 26 SLE patients and 30 wrists of 15 healthy controls were evaluated using US by two different experienced operators, blinded to the clinical data. A 14 MHz linear probe was used. Power Doppler (PD) was applied to evaluate the presence of synovial neoangiogenesis as a parameter of active local synovitis. The findings were correlated to the clinical evaluation, serological systemic disease activity parameters (ESR, C3 levels) and the SLE-disease activity score (SLEDAI). Statistical analysis was performed by the EPISTAT program.

RESULTS

Signs of synovitis were found in 22 wrists (42.3%). Synovial proliferation was present in 10 joints (19.2%), PD positivity in 5 (9.6%) and joint effusion in 13 (25%). Erosions were present in both wrists (3.8%) of one patient. Signs of tenosynovitis of one or more tendons were shown in 23 cases (44.2%). Ganglia were found in 2 joints (3.8%). Changes of the median nerve, joint dislocations, tendons' ruptures, cysts and nodules were never detected. In 14 wrists (26.9%) no alterations were found. There was no correlation between sonographic findings and clinical, laboratory and indexes signs of disease activity. In the control group the only alteration found was tenosynovitis in 1 joint (p < 0.0001).

CONCLUSION

US proved to be an useful technique to detect wrist joint alterations in SLE. These findings may help the physician to modulate treatment strategies and to perform a low cost monitoring of joint disease activity.

A new approach to studying angiogenesis in rheumatoid arthritis by means of power Doppler ultrasonography and measurement of serum vascular endothelial growth factor

OBJECTIVE

To evaluate angiogenesis as an essential component of pannus formation and cartilage destruction in rheumatoid arthritis (RA) using power Doppler ultrasonography (PDUS) and serum vascular endothelial growth factor (VEGF) measurement.

METHODS

Twenty-one RA patients with a painful and swollen wrist and 12 healthy controls were examined with ultrasound. By means of standard scans, vascularity near and inside the joint capsule was visualized with PDUS. Two trained investigators performed sonography. Representative video clips were stored and read by two independent investigators, under blinded conditions, with regard to the microvascular Doppler flow being either inside or outside the joint capsule and with respect to a qualitative estimate of the intensity of blood flow, according to a grading from 1 to 3. Serum levels of VEGF were measured with a standard quantitative sandwich ELISA.

RESULTS

The power Doppler mode identified increased synovial microvascular blood flow inside the joint capsule in 17 of 21 RA patients (81%) vs one of the healthy controls. We found large variation in serum VEGF levels in RA patients and in healthy controls. The degree of synovial vascularity determined by PDUS showed no correlation with the immediate serum VEGF level in the same patient.

CONCLUSION

The high correlation between intra-articular microvascular power Doppler flow and clinical synovitis in RA patients (P<0.0001) indicates that PDUS may be helpful in studying the role of synovial blood vessels in rheumatoid inflammation.

Vascularity and osteonecrosis of the wrist

This article outlines the vascular anatomy of the carpus, describing the extraosseous and intraosseus vascular systems and emphasizing the carpal bones at risk for osteonecrosis. Separate discussions of etiology, diagnosis, and treatment of osteonecrosis of the commonly involved carpal bones are included.

[Vascularized bone transfers in the wrist and hand]

More and more vascularised bone transfer (VBT) sites, free or pedicled, in the wrist and hand have been described since the 1980s. In the distal forearm, two main VBT: the fibula and the iliac crest, are used for large bone loss (> 6 cm) or for radio-carpal reconstruction. We report our experience of radio-carpal reconstruction using the distal-radio-ulnar joint transfer. At the carpal level, VBT are essentially used for "difficult" scaphoid pseudarthrosis: osteonecrosis, sclerotic bone or failures of conventional grafts and for lunate necrosis. Two pedicled VBT are frequently used for the scaphoid, a graft harvested from the antero-medial part of the distal radius (Kuhlmann) or a graft harvested from the postero-lateral part of the distal radius (Zaidemberg). For the trapezo-metacarpal joint, two new articular pedicle transfers can be used in some cases of trapezo-metacarpal arthritis. At the hand level, VBT are used for distal bone loss, "en bout de chaîne". Bone vascularisation is indispensable to preserve sub-chondral bone and avoid articular destruction. In children VBT are necessary to preserve the growth cartilage.

[Reconstruction of bone defect by vascularized fibular transfer after failed wrist arthroplasty]

A bone defect of 14 cm resulted after wrist implant removal because of loosening in a 46-year-old patient. Performing wrist arthrodesis the defect was reconstructed by a vascularized fibular transfer. Solid bone fusion was complete in six weeks. Free function of the digits was seen because of length reconstruction.

Wrist and hand overuse syndromes

Overuse syndromes in the wrist or hand can occur from repetitive use of the wrist and hand or from recurrent direct trauma to the hand area. Tendinitis syndromes due to overstretching or shear stress are seen commonly on both the extensor and flexor sides of the wrist. Overuse syndromes also can take the form of neurovascular syndromes, resulting in compression syndromes of the median, ulnar, and superficial branch of the radial nerve in the wrist area and trauma to the ulnar and digital vessels supplying the hand. Treatment in most cases involves rest with splinting, icing, and NSAIDs in acute cases, although surgical decompression is indicated in chronic or recurrent cases.

Subclinical joint involvement in psoriasis: magnetic resonance imaging and X-ray findings

Previous studies have shown that magnetic resonance imaging is more sensitive in assessing soft tissue and bone involvement in inflammatory arthritis than conventional radiography. Therefore the main objects of this study were to evaluate the frequency of hand involvement in psoriatic patients free from arthritic symptoms, and to compare the results with those of a healthy control population (age- and sex-matched). Twenty-five patients suffering from active nummular and/or plaque psoriasis with no arthritic signs or symptoms were studied together with 12 healthy control subjects. The articular structures of both hands in all patients were screened using both traditional radiological techniques and magnetic resonance imaging. Specifically, we examined: soft tissue swelling, periarticular effusion, joint effusion-synovial pannus, tendon sheath effusion, bone erosion, luxation, sub-luxation, bone cysts and subchondral signal intensity abnormalities. Sixty-eight percent of our psoriatic patients were found to be positive with at least one arthritic sign using magnetic resonance imaging, while with the standard X-ray procedure, only 32% of the same group of patients were found to be positive. Specifically, abnormal signal intensity in the subchondral focal areas were seen in 9 patients using the magnetic resonance imaging technique, while in the control group, no significant abnormalities were detected. A high percentage of psoriatic patients without apparent arthritic signs and symptoms were shown to have hand articular involvement, in particular in the distension of the capsular and periarticular oedema when examined with magnetic resonance imaging. In our experience, the use of magnetic resonance imaging allows a clear and adequate evaluation of the cartilage, bone and soft tissue material, and is diagnostically superior to X-ray in demonstrating clinically silent and radiologically invisible articular lesions. Moreover, the subchondral changes detected by magnetic resonance imaging were unexpected findings which could imply an ischaemic origin.

"Spaghetti wrist": management and results

A retrospective review of 60 patients with "spaghetti wrist" lacerations operated on by the authors between July of 1988 and June of 1996 was completed. Spaghetti wrist injuries were defined as those occurring between the distal wrist crease and the flexor musculotendinous junctions involving at least three completely transected structures, including at least one nerve and often a vessel. A total of 41 men and 19 women, average age of 29.0 years (range, 5 to 54 years), sustained spaghetti wrist injuries. The most frequent mechanisms of injury were accidental glass lacerations (61.0 percent), knife wounds (23.7 percent), and suicide attempts (8.5 percent). An average of 7.8 structures were injured including 5.8 tendons, 1.2 nerves, and 0.73 arteries. The most frequently injured structures were flexor carpi ulnaris (66.7 percent), median nerve (60.0 percent), flexor digitorum superficialis 2-5 (59.2 percent), ulnar nerve (58.3 percent), and ulnar artery (56.7 percent). A predilection for injury to the ulnar structures was observed. The flexor carpi ulnaris was more commonly injured than the more superficial central and radial palmaris longus (48.3 percent) and flexor carpi radialis (45.0 percent). The most common pattern of injury involved the ulnar nerve and artery and flexor carpi ulnaris, or so-called ulnar triad (41.7 percent). Combined median nerve, flexor carpi radialis, and palmaris longus lacerations occurred in 26.7 percent. Simultaneous lacerations of both median and ulnar nerves occurred in 23.3 percent. No distinct pattern of injury was noted in patients with simultaneous injury to both nerves. Simultaneous lacerations of both ulnar and radial arteries occurred in 6.7 percent; neither artery was injured in 33.3 percent. In the subset of 19 patients available for follow-up examination, range of motion was excellent in 12 patients and good in 7 patients. In 12 patients with sufficient follow-up, intrinsic muscle recovery was good in 7 patients and fair to poor in 5 patients. Sensory return was disappointing: seven patients recovered only protective sensation and five patients demonstrated return of two-point discrimination that ranged from 7 to 12 mm in three patients and from 2 to 6 mm in two patients.

Ulnar artery as a coronary bypass graft

BACKGROUND

The ulnar artery has been used as a coronary bypass graft in 8 patients when it was deemed unsafe to harvest the radial artery after evaluation of the arterial circulation in the forearm and hand.

METHODS

The ulnar artery was removed from the lower three quarters of the forearm, along with its satellite veins. Dissection was commenced distally near the wrist and extended proximally to where the ulnar artery passed between the two heads of origin of the flexor digitorum superficialis. The artery was divided distally above the wrist joint and proximally at a point immediately below the origin of the common interosseus artery.

RESULTS

Ten ulnar arteries were removed for use as coronary artery bypass grafts; two were rejected, one because of severe calcification and the other because of atherosclerotic occlusion. The remaining eight ulnar arteries were grafted successfully to coronary arteries other than the left anterior descending. No early hand or cardiac complications were observed.

CONCLUSIONS

The ulnar artery is an alternative coronary artery bypass graft that may be used when the radial artery is dominant and cannot be removed without risk. The ulnar artery is in close proximity to the ulnar nerve and harvesting has the potential to injure the nerve. Therefore, until the use of the ulnar artery has been more fully evaluated it should be used only when other options have been exhausted.

A modified approach to the flexor surface of the distal radius

Twenty-three preserved cadaver upper limbs were dissected to show the level of the nerve supply to flexor carpi radialis and the extent of exposure of a new approach to the flexor surface of the distal radius. We describe a new approach to the flexor surface of the distal radius in which both the radial artery and the median nerve are protected by muscles or tendons.

[The vascularization of the common synovial sheath and the tendons of the flexor muscles of the carpal tunnel]

The detailed anatomy of the tendon apparatus, the blood supply of the superficial (FDS) and profundus (FDP) flexor muscles and the blood supply of the common synovial sheath in the carpal tunnel were studied on 200 hundred upper extremities from fresh human cadavers. The injection of coloured latex or the aqueous solution of India ink and gelatin revealed a complex arterial network. Dissection of the carpal tunnel revealed the existence of different sources of the blood supply of the tendons of the flexor muscles and carpal sheath. The different sources and zones of vascularization are described. This study concerns the synovial and tendinous apparatus of the flexor muscles as well as their blood supply in the carpal tunnel. These data may be of interest hand surgeons.

[Arthroplasty of the wrist by island transfer of the inferior radio-ulnar joint]

In cases of advanced osteoarthritis of the wrist, in which the radiocarpal and midcarpal joint spaces have been destroyed, the authors propose island transfer of the distal radioulnar joint. They studied the blood supply of the distal radioulnar joint from the interosseous arteries on 40 fresh cadaver upper limbs. The anatomical study showed that the dorsal epiphyseal periosteal network was supplied by the lower perforator of the anterior interosseus artery in every case and by the posterior interosseous artery in 38 out of 40 cases. The distal radioulnar joint can be harvested "en bloc" and rotated 90 degrees so that the joint space can be placed in radio-carpal position while preserving its blood supply on the anterior interosseous pedicle. The authors describe their operating technique and present their first clinical case. This new operation represents a non prosthetic alternative to arthrodesis.

Flexor to extensor tendon transfers in the hand

We reviewed 49 cases of flexor to extensor tendon transfer following injury to the radial nerve (22) or brachial plexus (27). Post-operative follow-up average 5.6 years (0.5-12.5). Function was improved in 84% (41) of patients. 16% (8) reported no improvement; of these, four (50%) had associated vascular injuries. In those with improvement, impaired coordination and dexterity were reported by 79% (15 of 19) of the plexus injuries and in 64% (14 of 22) of the radial nerve palsies. Premature fatigue was noted by 89% (17 of 19) of plexus injuries and in 82% (18 of 22) of radial nerve palsies. The power of wrist extension averaged 22% of the contralateral side (8% to 80%), power of digital extension was 31% (5% to 130%), and power grip was reduced to 40% (5% to 86%).

Radiocarpal arthroscopy portals and normal anatomy

Wrist arthroscopy is now an accepted technique in the evaluation of radiocarpal intra-articular pathology. An understanding of the surface anatomic landmarks and articular anatomy is required to safely and effectively perform the technique. Multiple portals are used to arthroscopically view the radiocarpal joint and provide access for irrigation and surgical instruments.

Arthroscopic portals of the wrist: an anatomic study

Wrist arthroscopy has become an accepted diagnostic technique, and it is starting to be a useful therapeutic tool. Extensor tendons, the radial artery, and dorsal sensory nerve branches are at risk of injury during this procedure; however, understanding periportal anatomy should make wrist arthroscopy safer. Wrist arthroscopic portals were established in 19 fresh cadaver wrists, after which the limbs were dissected and periportal anatomy was described and quantified. The 1-2, 6R, and 6U portals were the most perilous, while the midcarpal, 3-4, 4-5, and distal radioulnar joint portals were relatively safe. Even "safe" portals had occasional adjacent sensory nerve branches and tendons. A safe technique of establishing wrist arthroscopy portals is emphasized.

Concomitant skeletal and soft tissue injuries

The diagnosis and treatment of those injuries most commonly seen in conjunction with distal radius fractures are reviewed in this article. Concomitant tendon, arterial, and nerve injuries often are associated with a high-energy mechanism of trauma. These injuries may complicate an already difficult fracture care plan, especially if the diagnosis of these injuries is delayed. Late tendon rupture and intercarpal injuries are discussed also.

Thickening of the synovium of the digital flexor tendons: cause or consequence of the carpal tunnel syndrome?

Using a monofilament wire suture, the radial and ulnar edges of the flexor retinaculum were approximated in 14 white New Zealand rabbits. As a result, the volume of the carpal tunnel was diminished, and "carpal tunnel syndrome" was produced. At various intervals after this procedure the animals were sacrificed. The median nerve and all the digital flexor tendons passing through the carpal tunnel were excised "en bloc", and sent for histological examination. Vascular proliferation with perivascular round cell infiltration and oedema, and large areas of fibroblastic activity were observed around the digital flexor tendons. This was probably due to increased vascular permeability secondary to ischaemic endothelial damage. These findings are similar to those observed in the synovium of patients operated on for carpal tunnel syndrome.

Flexor tendon lacerations in zone V

Twenty-three patients with zone V flexor tendon lacerations rehabilitated by the Kleinert protocol were studied at an average of 46 months after trauma. Hand function was subjectively normal in only eight. Of fourteen patients who were employed at the time of injury, eight returned to their original occupations. Eight others were working at other jobs, and we considered six more capable of employment. Only one had a poor functional result that precluded occupational use of the hand. Pinch/grip strengths recovered to 85%/79% of the uninvolved side. Independent flexor digitorum superficialis/flexor digitorum profundus action was present in only seven patients. Sixteen regained full digital flexion. Extension loss averaged 25% at the wrist and 10% in each digit. As assessed by static two-point discrimination, sensibility was poor after associated median and ulnar nerve transections; this did not preclude good objective functional results. Complications included two tendon ruptures, proximal interphalangeal hyperextension in the presence of an unrepaired flexor digitorum superficialis, and limited motion in two patients after poor compliance in therapy. Tenolysis was needed in 4 of the 23. We now use a modified Duran technique for noncompliant patients and in those who are unable to extend their PIP joints because of weak intrinsic muscles.

The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk

The arterial blood supply of the distal radioulnar joint was investigated in 35 upper extremities taken from 22 fresh cadavers (11 newborns and 11 adults using the India ink injection and tissue-clearing techniques according to Spalteholz). Microvasculature of the articular disk of the distal radioulnar joint was also performed in 35 articular disks taken from 22 fresh human cadavers, 11 newborn and 11 adults using the same technique. It was found that the general blood supply to the joint is received mainly from the palmar and dorsal branches of the anterior interosseous artery. These branches, after dividing at the proximal border of the pronator quadratus, arborize in a fanlike fashion around the joint and their small ramifications penetrate and vascularize the capsule and the articular disk from the palmar, dorsal, and medial sides. The terminal branches of the anterior interosseous artery reinforced by the posterior interosseous artery and a small branch of the ulnar artery give the direct peridiscal vessels to the palmar, medial, and dorsal margins of the articular disk, which arborize and anastomose with one another and form the terminal capillary networks that end at the peripheral segments of the disk in a series of terminal capillary loops, leaving the inner segments devoid of blood vessels. The posterior interosseous artery anastomoses at the distal part of the forearm with one of the terminal rami of the dorsal branch of the anterior interosseous artery and, in that way, contribute to the vascularization of the dorsal capsule of the distal radioulnar joint. The ulnar artery gives off a small branch that anastomoses with one of the terminal ramifications of the palmar branch of the anterior interosseous artery and contributes to the formation of a small arterial arch on the anteromedial side of the distal ulna, supplying the anteromedial capsule and the basistyloid area of the ulna. Both ulnar and radial arteries contribute to the vascularity of the joint through the collateral network of the palmar and dorsal carpal arches. In the articular disk, the major central portion of the disk is avascular and only its peripheral, palmar, medial, and dorsal margins are vascularized. The proportion of vascularized zone to avascular zone depends on the age of the subject and, in newborns, is approximately 33%. In adults, only 25% of the peripheral segments are vascularized.(ABSTRACT TRUNCATED AT 400 WORDS)

Intravenous regional administration of methylprednisolone in rheumatoid arthritis

Intravenous regional administration of corticosteroid (IVRAS) in the treatment of rheumatoid arthritis of the hand has not been reported previously. The method is based on a modification of Bier's block, with substitution of corticosteroid for local anaesthetic. Twenty-two patients were assessed in this double-blind, placebo-controlled study. The technique was safe and effective in improving grip strength, with a group mean improvement of more than 50%. Because suppression of endogenous cortisol production 24 h after treatment was commensurate with the dose of methylprednisolone used (40 mg), we could not exclude that the response may have been due to systemic steroid. Further studies are required to define the real value of IVRAS as it may offer alternative treatment of the joints and tendons within the hand and wrist in some patients rather than more prolonged oral therapy or individual, multiple joint or sheath injections.

The microvasculature of the triangular fibrocartilage complex: its clinical significance

The microvascular anatomy of the triangular fibrocartilage complex was investigated in 10 cadaver specimens by histology and tissue clearing (Spalteholz) techniques. It was found that the triangular fibrocartilage of the wrist is supplied by small vessels that penetrate the triangular fibrocartilage complex in a radial fashion from the palmar, ulnar, and dorsal attachments of the joint capsule and supply the peripheral 10% to 40%. The inner (horizontal) portion is avascular, and no vessels cross the radial attachment of the triangular fibrocartilage complex. The results of this study suggest that tears in the periphery of the triangular fibrocartilage complex may have sufficient blood supply to mount a reparative response and, in theory, can be repaired. However, tears that occur in the center and along the radial attachment do not have immediate access to a blood supply and are not likely to heal.

Histologic anatomy of the triangular fibrocartilage

Histologic examination of the TFC reveals parallel, longitudinally oriented collagen fibers peripherally, while the more central articular disc is made up of interweaving obliquely oriented sheets of collagen fibers. This suggests a peripheral region experiencing tensile loads between the region of origin from the radius and the area of insertion into the ulna. The fiber orientation in the central region is more compatible with a structure experiencing multidirectional stresses. The articular disc origin from the radius is reinforced by collagen bundles projecting out from the radius for 1 to 2 mm. A large number of traumatic tears are oriented parallel to the radial origin of the TFC and located approximately 1 to 2 mm from the origin site. This corresponds to the junction of the short, radially oriented fibers and the remainder of the articular disc. The inner 80% of the articular disc is avascular, as is its radial attachment. Traumatic tears in this region would have a low healing potential unless some method for introducing additional vascularity was undertaken, such as reattachment through drill holes in the radius, allowing neovascularization of this otherwise avascular region.

[Study of microcirculation by the method of polarography in deforming osteoarthrosis and rheumatoid arthritis]

Disorders in microcirculation in the periarticular joints was diagnosed in the study of 60 patients with deforming osteoarthrosis and 30 patients with RA.

Carpal tunnel: MR imaging. Part I. Normal anatomy

To correlate the important structures of the carpal tunnel demonstrated on magnetic resonance (MR) images with gross anatomy, the authors imaged the wrists of 20 normal volunteers and nine cadavers. The cadaver specimens were sectioned in the same planes in which they were imaged, and three other specimens were dissected. The anatomy was directly correlated with the imaged morphology. Axial images delineated well the bone and ligament walls of the carpal tunnel. The median nerve was well delimited and of moderate signal intensity. It was surrounded in some cases by fat but was consistently bound by specific tendons. The ulnar nerve and artery were visualized as they traversed the Guyon canal to their division into superficial and deep branches. Coronal images permitted optimal visualization of the triangular fibrocartilage and the radial and ulnar collateral ligaments. Quantitative studies indicated that the normal median nerve does not significantly increase in size within the carpal tunnel but does become more flattened at the level of the pisiform bone. The normal flexor retinaculum may have a slight palmar bowing.

Carpal tunnel: MR imaging. Part II. Carpal tunnel syndrome

The magnetic resonance (MR) images of 14 wrists of patients with carpal tunnel syndrome (CTS) were studied. Four general findings visible regardless of the cause of CTS included swelling of the median nerve, best evaluated at the level of the pisiform bone; flattening of the median nerve, most reliably judged at the hamate level; palmar bowing of the flexor retinaculum, best visualized at the level of the hamate bone; and increased signal intensity of the median nerve on T2-weighted images. Findings related to cause were tendon sheath edema in traumatic tenosynovitis, synovial hypertrophy in rheumatoid tenosynovitis, a ganglion cyst, and excessive amount of fat within the carpal tunnel, a persistent median artery, and a large adductor pollicis muscle. Knowledge of these findings may permit more rational choice of treatment. In four cases in which symptoms persisted after surgery, findings valuable in explaining or predicting the failure included incomplete incision of the flexor retinaculum, excessive fat within the carpal tunnel, persistent neuritis of the median nerve, and development of neuromas.

Effects of ischaemia upon reflex electromyographic responses evoked by stretch and vibration in human wrist flexor muscles

1. The reflex electromyographic responses evoked in a wrist flexor muscle, flexor carpi radialis (f.c.r.), by forcible extension of the wrist ('stretch') and by vibration of the flexor tendon have been studied in normal subjects. Reflexes were elicited during the maintenance of a low level of voluntary flexor contraction (5% maximum). Stretch regularly produced a relatively prolonged (ca. 100 ms duration) increase in e.m.g. activity which was usually divisible into short-latency (ca. 25 ms, M1) and long-latency (ca. 50 ms, M2) peaks. Vibration produced a single, phasic peak, at short latency, with no sign of an accompanying long-latency wave comparable to the M2 stretch response. 2. Ischaemia was induced by inflation of a blood-pressure cuff around the upper arm and its effects upon the reflex patterns were studied. During ischaemia M1 stretch responses showed a more rapid and pronounced decline than did M2 responses and were abolished before voluntary power was appreciably affected. Vibration-evoked short-latency peaks changed in an essentially parallel manner to M1 stretch reflexes. During recovery from ischaemia M2 reflexes were restored before short-latency responses. 3. The patterns of reflex reductions in e.m.g. upon withdrawal of stimulation were also studied. Such troughs in activity, under non-ischaemic conditions, regularly commenced at short latency and were of relatively small amplitude. The records of several of the subjects, and particularly ones obtained during ischaemia, suggested that release of stretch (with concomitant stretch of antagonists) could elicit an additive, long-latency decline in e.m.g. The existence of any such separate, delayed component was never observed upon termination of vibration. 4. Measurements of changes in the latencies and durations of reflex components, accompanying the progression of ischaemia, indicated that depression of early reflex activity resulted in part from increases in the latencies of these initial peaks but predominantly reflected simultaneous and separate reductions in their amplitudes. 5. The generation of short-latency reflexes by stretch and vibration, both of which stimuli powerfully excite muscle spindle primary endings, and the marked susceptibility of these responses to ischaemia supports their being mediated by group Ia afferents. The contrasting behaviour of M2 stretch responses, both regarding their absence with vibration and their resistance to ischaemia, suggests that they depend crucially upon a separate group of reflex afferents.(ABSTRACT TRUNCATED AT 400 WORDS)

Traumatic Rupture of Median Artery an Unusual Cause for Acute Median Nerve Compression

Previous case reports of haemorrhage into the carpal tunnel causing median nerve compression were extraneural and usually associated with a blood dyscrasia although Watson Jones reported one due to direct trauma and Hayden recorded spontaneous intraneural haemorrhage not associated with trauma. We describe a case of intraneural haemorrhage, involving the median nerve in the carpal tunnel, due to indirect trauma and not associated with a blood dyscrasia. The condition required intraneural decompression to obtain relief.

Blood flow changes at the wrist in manual workers after preventive interventions

Radial and ulnar artery circulatory changes at the wrist were studied at the work site in manual workers performing repetitive tasks to compare the effects of two preventive interventions, exercise and rest. The Doppler method was used for assessment of blood flow velocity, and systolic blood pressure measurements were made on 16 right hand-dominant female workers in a suture manufacturing industry. Radial and ulnar blood flow velocity decreased while systolic blood pressure at these arteries remained stable after 1 1/2 hours of manual work. After 5-minute interventions of either exercise or rest, blood flow velocity increased, radial blood pressure remained stable, and ulnar blood pressure decreased. A 5-minute exercise program produced greater increases in radial blood flow velocity than did a 5-minute rest program. Brief exercise programs have been shown to improve circulation at the wrist after circulation was compromised by the performance of manual work. Such programs may offer one practical method of preventing soft tissue injuries related to the sustained compromise of blood flow at the wrist.

Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance

This vascular injection study of the triangular fibrocartilage (TFC) was carried out in 12 fresh cadaver arms--eight adults and four infants--with Ward's blue latex. The TFC receives its blood supply from (1) the ulnar artery through its palmar and dorsal radiocarpal branches, (2) the dorsal branch of the anterior interosseous artery, and (3) the palmar branch of the anterior interosseous artery. These vessels are arranged in a radial fashion in relation to the fibrocartilage. Histologic sections of the TFC reveal vascularity in the outer 15% to 20% of the disc, and the rest is avascular. On the basis of these findings, we feel that tears of the TFC in its vascular zone have the potential to heal if repaired and those in the central avascular zone do not have this potential.

The vascularity of the wrist. Identification of arterial patterns at risk

The intraosseous and extraosseous vascularity of carpal bones was studied in 75 cadaver limbs. Vascular patterns were correlated with the clinical incidence of avascular necrosis, and at-risk patterns of vascularity were identified. The carpal bones were found to fall into three groups. Group 1, which consisted of the scaphoid, the capitate, and eight percent of the lunates, had either vessels entering only one surface or large areas of bone that were dependent on a single vessel. This group was the most vulnerable to posttraumatic avascular necrosis. The bones of Group 2, the hamate and the trapezoid, were characterized by the absence of internal anastomoses. Although these bones are theoretically at risk, they do not undergo avascular necrosis. Group 3 bones, which included the trapezium, the triquetrum, the pisiform, and 92% of the lunates, had rich internal anastomoses and were at least risk of undergoing avascular necrosis. Examination of the arterial anatomy of bones that undergo avascular necrosis in other regions of the body led to a classification based on the types of vascular interruptions that place particular bones at risk. In some, i.e., the scaphoid and the capitate, a pure intraosseous disruption resulted in avascular necrosis; in others, i.e., the femoral head and a small percentage of lunates, an extraosseous disruption was sufficient to produce avascular necrosis. A third class, which included the talus and the majority of lunates, had an adequate intraosseous blood supply and good extraosseous vascularity. This pattern required severe extraosseous or a combination of intraosseous and extraosseous injury to lead to avascular necrosis.

[Extrinsic and intrinsic vascularization of the scaphoid and lunate bones]

This work was performed on 50 wrist dissections. The scaphoid is situated in the territory of the radial artery. Two extracapsular vascular pedicles are constant: --the lateral pedicle arises in the anatomical snuff-box, --the anterior pedicle arises in the "wrist pulse" area and passes behind the flexor carpi radialis. It lies on the radio-carpal ligaments. THe intra-capsular pedicles approach the scaphoid from its proximal pole. There are anastomoses and they lie on the deep dorsal and palmar ligaments. The multiple anastomotic branches may form an inconstant pedicle. The lunate is supplied by frequent but inconstant arterial pedicles. They are palmar and dorsal, superficial and deep (intra-capsular), distal and proximal, and lie on the radiocarpal ligaments. They originate from the three principal arteries of the hand or their branches. Anastomotic connections exist between them; if the vascular arrangement is complete, it is very reliable; when it is incomplete, it predisposes to Kienböck's disease. There is a close functional relationship between the scaphoid and the lunate. The vulnerability of these two bones to trauma which can also affect their ligaments explains the relative frequency of ischemic complications.

[Comparative drug therapy study with scintigraphic control research]

By means of the 99m-Tc-pertechnitate joint scintigraphy the authors try to document the effect of antirheumatic drugs in 62 patients with rheumatoid arthritis. By measuring the changes of the synovial blood circulation, conclusions are drawn as to the degree of inflammation. When trying to make a quantitative assessment of the changes of inflammation as compared with a standardised reference region, particularly on the wrist joint, it was found that the activity increased on the reference region on the forearm and that proved to be a possible source of error. The reason for this may be the early involvement of vessels in rheumatoid arthritis. For further calculations it will be necessary to set up joint and radio-nuclide-specific standards as reference points.