Alan E. Freeland

Intracarpal Soft-Tissue Lesions Associated with an Intra-Articular Fracture of the Distal End of the Radius*

Sixty patients who had a displaced intra-articular fracture of the distal end of the radius were managed with manipulative reduction and internal fixation performed under both fluoroscopic and arthroscopic guidance. According to the AO/ASIF classification system, seven fractures were type B1, two were type B2, three were type B3, thirteen were type C1, twelve were type C2, and twenty-three were type C3. Forty-one patients (68 per cent) had soft-tissue injuries of the wrist, including tears of the triangular fibrocartilage complex (twenty-six patients), the scapholunate interosseous ligament (nineteen), and the lunotriquetral interosseous ligament (nine). Thirteen patients had two soft-tissue injuries. Intracarpal soft-tissue injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface or the radius.

Open hand fractures: An analysis of the recovery of active motion and of complications

Seventy-five of 104 patients who underwent operative fixation of open hand fractures were reviewed between 6 months and 7 years after injury (average, 17 months). There were 140 fractures involving 125 fingers. Results, evaluated on the basis of total active range of digital motion achieved at final follow-up, correlated highly with severity of soft tissue injury. When open fractures of comparable severity were contrasted between groups that did and did not require additional extension by incision to achieve acceptable reduction and stabilization, there was some additional loss of active range of motion in the surgically treated group. Metacarpal fractures had significantly better outcomes than phalangeal fractures. Fractures involving the proximal phalanx or the proximal interphalangeal joint had the poorest prognosis, especially when they were associated with tendon injury. There were significant complications in 13 fingers. Infection and late amputation were related to wound severity.

Arthroscopically Assisted Reduction of Intraarticular Distal Radial Fractures

Anatomic restoration of the joint surface and extraarticular alignment is the goal in management of displaced distal radial fractures. Arthroscopy provides well lit, magnified conditions in which to reconstruct the fractured joint surface and to detect and manage intracarpal soft tissue injures associated with distal radial fractures. Percutaneous and limited open reduction techniques combined with wrist arthroscopy in the arthroscopically assisted management of displaced distal radial fractures is described.

Rehabilitation for proximal phalangeal fractures

Proximal phalangeal fracture stability is crucial for the initiation of early and effective exercises designed to recover digital and especially proximal interphalangeal joint motion. Active digital flexion and extension exercises are implemented by synergistic wrist motion. Joint blocking exercises and active tendon gliding exercises in protective blocking splints are instrumental elements of early treatment. Dynamic splinting and serial finger casting are used in recalcitrant, severe, and late presenting cases. Surgical release is a last resort in regaining proximal interphalangeal joint motion. This measure is reserved for a failure of treatment when residual proximal interphalangeal joint contracture is persistent and severe enough to cause serious impairment of digital motion and hand function.

Delayed primary bone grafting in the hand and wrist after traumatic bone loss

Seventeen patients had 21 bone graft operations as part of the overall delayed primary management of hand and wrist wounds. All bone graftings were performed within 10 days of injury. Internal or external fixation was used in all cases, and all wounds healed without infection. Complications included a fibrous union at one bone graft juncture and one malunion. Follow-up was from 3 months to 7 years. Successful delayed primary bone grafting requires a well-decompressed and surgically-clean wound, good blood supply, adequate fixation, and secure soft-tissue cover. If these conditions cannot be met, bone grafting should be deferred and performed in the conventional manner. The advantages of delayed primary bone grafting are: primary bone healing, a shorter rehabilitation period, fewer operations, avoidance of wound contracture, and bone grafting in a well-vascularized scar-free bed.

IMAGING OF THE HAND AND WRIST

This article reviews many of the most commonly used modalities for imaging the hand and wrist. Particular attention is paid to proper radiographic positioning, with emphasis on the four-view wrist series. Standard wrist measurements are detailed, and wrist arthrography is also discussed. Techniques for cross-sectional imaging, computed tomography, and MR imaging are reviewed, and several examples are presented as to where MR imaging is diagnostically valuable.

Displaced vertical fracture of the trapezium treated with a small cancellous lag screw

A displaced vertical fracture of the trapezium with associated dislocation of the base of the thumb metacarpal was restored by the cancellous compression lag screw technique. Excellent results were achieved in terms of union, joint restoration, and function.

Techniques of Wrist Arthroscopy

Arthroscopy has revolutionized the practice of orthopaedics by providing the technical capability to examine and treat intra-articular abnormalities directly. The development of wrist arthroscopy was a natural evolutionary progression from the successful application of arthroscopy to other, larger joints. Wrist arthroscopy has seen considerable growth since Whipple et al. reported their original description of the techniques that they developed for viewing the anatomy of the wrist56. The wrist is a labyrinth of eight carpal bones, multiple articular surfaces with intrinsic and extrinsic ligaments, and a triangular fibrocartilage complex, all within a five-centimeter interval. This perplexing joint continues to challenge clinicians with an array of potential diagnoses and treatments. Wrist arthroscopy allows direct visualization of cartilage surfaces, synovial tissue, and ligaments under bright illumination and magnification. While most acute sprains of the wrist with normal radiographic findings resolve after temporary immobilization, how to further evaluate the patient who does not have improvement after such treatment is controversial. Tricompartmental wrist arthrography has historically been the so-called gold standard for the detection of intra-articular abnormalities9,10,43,54. However, the proved ability of wrist arthroscopy to enable detection and simultaneous treatment of wrist injuries, as well as the introduction of magnetic resonance imaging, has markedly altered this situation28,38,44. Adolfsson used arthroscopy to examine 144 patients who had posttraumatic wrist pain and normal findings on standard radiographs1. Ligamentous changes were observed in seventy-five patients; lesions of the triangular fibrocartilage complex, including lunotriquetral instability, in sixty-one patients; and varying degrees of scapholunate instability, in fourteen patients. The indications for wrist arthroscopy continue to expand as new techniques and instrumentation are developed. Diagnostic indications include assessment of tears of the interosseous ligaments and determination of whether they are partial or complete …

Traumatic Below-elbow Amputations

Prehension, intelligence, and erect posture distinguish humans from lower animals. Hands are instrumental for our survival and welfare. We use our hands when we work, recreate, and communicate. A handshake, a touch, a sign, or signal has significant social and communicative meanings. Hands play a major role in defining the skill level of our activities and our level of social expression and integration. Indeed, refined psychomotor precision of hand function may distinguish some individuals among us, gifting society with its more skilled craftsmen, surgeons, artisans, musicians, athletes, and the like in a highly digital world. For others, their hands are critical in providing and caring for their families. Injury severity scores may identify the majority of patients that require amputation; however, injury severity scoring system predictions in individual patients may be problematic and should be used with caution. Amputees require comprehensive multidisciplinary treatment and compassion so that they can successfully overcome their losses. Ultimately, the patients must change, adjust, and adapt to successfully reintegrate themselves into their families, peer groups, job settings, and society as a whole. Early amputation may decrease the incidence and severity of phantom pain compared to amputation after the failure of reconstruction. Early prosthetic fitting, training, and physical rehabilitation; early psychological and sociological support; and early return to work facilitate successful functional recovery. Psychological recovery may be a more arduous and extended process than physical recovery. We must teach our amputees from the outset to use their losses as an incentive for success, assist them to regain their quality of life, and encourage them to act as role models for and to educate others.

Metacarpal fractures in athletes: treatment, rehabilitation, and safe early return to play.

Specialty gloves and buddy taping of adjacent fingers may cushion impact and dissipate twisting forces so that hands, thumbs, and fingers are protected during play. When fractures occur, athletes must be protected from contact until healing has progressed to a point where reinjury or complications are unlikely and performance standards and expectations can be met. This article outlines a program of fracture management principles and progressive graduated rehabilitation that phase the hand-injured athlete first into general conditioning and non-ball-handling drills, then into return to hand impact activities, body contact, ball handling, and catching with the use of protective hand gear. At this point, specialized playing orthoses, gloves, or taping may be added to the treatment regimen. Batting, the use of golf clubs, and racquet handling occur later, and finally throwing with precision, distance, velocity, and frequency is initiated. The importance of the particular sport, the position played, and hand dominance are factored into the decision-making processes. Safety of the patient and opponents is paramount. Extra-articular metacarpal fractures are discussed as a prototype for treatment, rehabilitation, and early safe return to play because of their frequent occurrence in athletes.