Daniel C. Riordan

Arthrodesis of the Wrist: A Surgical Technique

A surgical technique is described for unilateral arthrodesis of the wrist through a radial wrist approach with an inner iliac-bone graft. Emphasis is placed on the position of the arthrodesis, graft placement, inclusion of the second and third carpometacarpal joints with the fusion mass across the radiocarpal joints, avoidance of the distal radio-ulnar joint and other significant surgical details. In twenty-four patients treated by this method over a ten to twelve-year period results were successful in twenty-three.

Tendon transplantations in median-nerve and ulnar-nerve paralysis.

1. The typical claw-hand deformity is caused by non-functioning interossei and lumbricales resulting from median-nerve and ulnar-nerve involvement regardless of the etiology. Function of the long flexors and extensors is still present and the resulting imbalance gradually causes the deformity to develop. 2. According to Bunnells and Fowlers concepts of finger extension, both the long extensors and the intrinsics (interossei and lumbricales) act synergistically to extend the distal two phalanges. Fowler further states that either the long extensors alone or the interossei alone can extend the distal two phalanges, provided the proximal phalanges are not allowed to extend beyond 180 degrees. 3. Bunnells and Fowlers concepts are partly proved by splinting in radial-nerve paralysis. Here the only force applied is extensor force on the proximal phalanges and full finger extension is possible. It is done by the intrinsic function still remaining. In combined median-nerve and ulnar-nerve paralysis, full extension of the distal two phalanges can be restored by block of the proximal phalanx at 180 degrees or less of extension, proving that the long extensors can extend the distal two phalanges if the proximal phalanges are stabilized. 4. The Bunnell multiple sublimis transplantation for paralysis of the median and ulnar nerves gives excellent results in those cases in which there are sublimis muscles suitable for transplantation and in which the deformity is of recent origin. 5 The Fowler operation for restoration of full extension in median-nerve and ulnar-nerve paralysis consists in transplanting the extensor-indicis proprius and extensor digiti quinti through the interosseous space, through the lumbrical canal anterior to the transverse metacarpal ligament, and inserting it into the combined intrinsic extensor aponeurosis. This procedure gives excellent results in those cases in which the sublimis muscles are not suitable for transplantation, and in which the deformity is severe or has been present for a long time. The limitation of wrist flexion resulting from this procedure is helpful in overcoming the claw deformity. 6. The same force can be exerted by a pure tenodesis operation in which one half of the extensor carpi radialis longus and one half of the extensor carpi ulnaris are used. Each tendon is split into two slips and inserted in the same manner as in the Fowler transplantation. The tenodesis procedure described here is recommended for those cases in which insufficient extensor power is present to allow use of the extensor indicis proprius and extensor digiti quinti for the Fowler transplantation and those in which the sublimis muscles are too weak for the Bunnell transfers. 7. The three methods of tendon transplantation for the correction of the claw-hand of median-nerve and ulnar-nerve paralyses discussed here can be used in nearly all cases. The only cases not suitable for such tendon transplantations are those with secondary skin contractures and fixed joint contractures; these require joint arthrodeses. It should be obvious that great care must be exercised in selecting the proper procedure for each individual case.

INTRINSIC CONTRACTURE IN THE HAND AND ITS SURGICAL TREATMENT

Intrinsic contracture in the hand is a crippling entity which is often unrecognized. The hand assumes a typical position with flexion of the metacarpophalangeal joints and extension of the interphalangeal joints. The thumb may be involved, and may exhibit marked flexion of the metacarpophalangeal joint and hyperextension of the interphalangeal joint. The loss of function is considerable,—the patient loses the essential functions of pinch and grasp. There are many possible causes,—ischaemia of the small hand muscles, spasm of the intrinsic muscles as found in rheumatoid arthritis and leprosy, and fibrosis resulting from direct trauma or thermal injuries. The treatment of choice is active splinting coupled with selective surgical excisions of the extensor aponeurosis, as suggested by Littler. The oblique fibers of the extensor hood are removed, thus releasing the extensor contracture; but the transverse fibers are preserved, thus retaining interphalangeal extension. This is best done through a single dorsal mid-line incision. Postoperatively, the patients hand is splinted with the metacarpophalangeal joints at 180 degrees, but with the interphalangeal joints left free for the active motion that is to begin on the first postoperative day. By means of active splinting and this relatively simple surgical procedure, the vital functions of pinch and grasp are restored to the intrinsically contracted hand. Since 1951 we have done this operation on twelve patients. Good results were obtained in all of these patients. One of the early patients in the series demonstrated slight clawing of one finger, due to excessive resection of the transverse fibers of the extensor aponeurosis. This difficulty was not encountered in the later cases in the series.

Mycobacterium marinum (Atypical Acid-Fast Bacillus) Infections of the Hand: A REPORT OF SIX CASES

Six cases of Mycobacterium marinum infections of the deeper structures of the hand are described which clinically and histologically were indistinguishable from tuberculosis. The infections became worse with steroid therapy. Surgical debridement with appropriate drug therapy (ethambutol or rifampin) was the treatment of choice. The organism must be suspected and then cultured at 30 to 32 degrees centigrade instead of the usual 37 degrees.

Reconstruction Of A Metacarpophalangeal Joint With A Metatarsal Transplant

Experience has emphasized the importance (1) of completely excising all cicatricial tissue from the site which is to receive the transplant; (2) of re-establishing complete intrinsic-muscle control of the proximal and distal joints of the finger; and (3) of preventing anterior subluxation by reconstructing the extensor mechanism and by splinting the finger in complete extension during the period of immobilization.