David J. Slutsky

Wrist Arthroscopy: Current Concepts

Wrist arthroscopy has steadily grown from a mostly diagnostic tool to a valuable adjunctive procedure in the treatment of myriad wrist disorders. The number of conditions that are amenable to arthroscopic treatment continues to grow. A detailed knowledge of the topographical and intracarpal anatomy, however, is essential to minimize complications and maximize the benefits. Although wrist arthroscopy can identify an anatomic abnormality, it cannot be used to differentiate between an asymptomatic degenerative condition versus a pathologic lesion that is the cause of wrist pain. A thorough wrist examination is still integral to any arthroscopic assessment. This article focuses on the methodology behind a normal arthroscopic wrist examination and discusses some of the more standard arthroscopic procedures along with the expected outcomes.

Current Innovations in Wrist Arthroscopy

It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.

The Incidence of Dorsal Radiocarpal Ligament Tears in Patients Having Diagnostic Wrist Arthroscopy for Wrist Pain

PURPOSEnThe goal of this study was to examine the incidence of dorsal radiocarpal ligament (DRCL) tears in patients having diagnostic arthroscopy for chronic wrist pain.nnnMETHODSnA 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.nnnRESULTSnThere 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.nnnCONCLUSIONSnDRCL tears are commonly seen with injuries to the primary wrist stabilizers. Recognition of this condition and further research into treatment methods are needed.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnDiagnostic IV.

Use of nerve conduction studies and the pressure-specified sensory device in the diagnosis of carpal tunnel syndrome.

Sixty-nine patients with signs of carpal tunnel syndrome (CTS) underwent nerve conduction studies (NCS) and testing with the Pressure-Specified Sensory Device (PSSD). A total of 102 tests were performed (28 bilateral). Twenty patients underwent a carpal tunnel release and were retested after 4 to 6 months. The Symptom Severity Score (SSS) was calculated before and after surgery. A control group of 20 hands in 10 asymptomatic volunteers underwent identical testing. The NCS sensitivity was 87% with a specificity of 90% whereas the PSSD sensitivity was 81% with a specificity of 65%. The combined sensitivity of the two tests was 93%. In the operative group the SSS improved from a mean of 3.34 pre-operatively to 1.95 postoperatively. The NCS improved in 19/21 hands whereas the PSSD improved in 16/19 hands. The non-invasive SSS and PSSD can increase the diagnostic yield in CTS, especially when the NCS are normal.

The Management of Digital Nerve Injuries

A tension-free coaptation is a key factor for the successful outcome of any nerve repair. A variety of host factors influence the outcome of digital nerve repair more than the type of repair per se. Although autologous graft remains the reference standard for reconstruction of any critical digital nerve defect, allografts and conduits have assumed an increasing role.

Granular cell nerve tumor in the hand: case report.

Granular cell tumor of a digital nerve is extremely rare; I could identify only 2 previous reports in the literature. I present a case of a granular cell tumor arising from an index digital nerve that was treated with wide resection and nerve graft reconstruction.

Creation of an opposable small finger by muscle transfer

We present a case of a child born with metacarpal synostosis of the index, long, and ring fingers associated with a simple syndactyly of the small finger and an absent thumb. At age 7 months, a syndactyly release with skin grafting to the small finger was accomplished so that it became the new thumb. At age 4 years, one of the muscles on the radical border of the hand was transferred to the small finger to act as an opposition transfer. At follow-up, the transfer contracted well and the functional capability of the hand was improved. This operation will not often be used but should be considered for the occasional patient with congenital anomalies.