David P. Green

Operative hand surgery

This two-volume set provides coverage of hand surgery. The third edition contains new chapters on wrist and elbow arthroscopy, principles and techniques of AO fixation, microneural reconstruction and management of complex open injuries. A section on microsurgery has been completely revised.

Open reduction of carpal dislocations: Indications and operative techniques

Based on their personal experience with 49 carpal dislocations in 46 patients, the authors suggest the following in the management of the acute injury: (1) Dorsal trans-scaphoid perilunate dislocation. After closed reduction, if the scaphoid is not anatomically reduced, primary open reduction and internal fixation with Kirschner wires is advised. A volar (Russe-type) approach gives adequate exposure, and bone grafting probably is not necessary. Satisfactory results can be achieved if the operation is done anytime within 2 weeks of injury. (2) Dorsal perilunate and volar lunate dislocation. Since cineradiographic studies show clearly that the lunate dislocation is usually the end stage of a perilunate dislocation, these injuries are treated identically after the initial closed reduction. Indications for open reduction are rotary subluxation of the scaphoid or lunate instability (dorsiflexion instability or volar subluxation). A dorsal approach is adequate for scaphoid subluxation alone, but combined dorsal plus volar approaches should be used for volar subluxation of the lunate with rotary subluxation of the scaphoid. Best results are achieved with open reduction as soon after the injury as possible. Factors in this series which were associated with poorer results were volar dislocation of the proximal pole of the scaphoid with the lunate, severely comminuted radial styloid fractures, extensive osteochondral fractures of the carpal bones, and late open reduction of rotary scaphoid subluxation.

Diagnostic and therapeutic value of carpal tunnel injection

This retrospective study documents the diagnostic and therapeutic value of steroid injections in patients with carpal tunnel syndrome. Two hundred eighty-one injections in 233 patients were done by one surgeon who used the same technique. Adequate follow-up ranging from 6 to 45 months was obtained in 199 patients (222 wrists). Injection of the carpal tunnel is an effective, albeit usually transient, therapeutic modality. Eighty-one percent of the patients obtained good or complete relief lasting from 1 day to 45 months. In most of these, symptoms began to recur after about 2 to 4 months (average 3.3 months), but in only 46% were recurrent symptoms severe enough to warrant surgical treatment. Twenty of the patients injected had no recurrence of symptoms for periods ranging from 10 to 45 months. Results of this study suggest that carpal tunnel injection is also a reasonably accurate diagnostic test. Ninety-nine wrists in 89 patients were subsequently treated surgically. Correlations between results of injections and subsequent operations indicate that a good response to injection is an excellent diagnostic and prognostic sign. However, the converse is not true; poor relief from injection does not necessarily mean that the patient is a poor candidate for surgery.

Wrist arthrodesis in post-traumatic arthritis: A comparison of two methods

The Arbeitsgemeinschaft für Osteosynthesefragen arthrodesis technique is compared with the proximal row carpectomy technique with radiocapitohamate arthrodesis for patients with traumatic and degenerative arthritis of the wrist. Both techniques gave satisfactory functional and x-ray film results in 85% of the patients. Grip strength measured on the Jamar dynamometer at settings 1-5 was 77-83% of the opposite in the dominant extremities and 56-82% of the opposite in the nondominant extremities. Despite the decrease in grip strengths after wrist fusion, grip strength curve patterns were similar for operated and nonoperated extremities. There were no statistically significant differences in grip strength between the two groups. Patients who did not have index and long ray carpometacarpal joints fused had pain at that level requiring a second procedure to arthrodese the joints. Index and long finger carpometacarpal joint arthrodesis at the time of wrist arthrodesis is recommended in patients with heavy labor jobs.

Pisotriquetral arthritis: A case report

Degenerative arthritis of the pisotriquetral joint was diagnosed by point tenderness over the pisiform and crepitus elicited by lateral movement of the pisiform on the triquetrum. It was confirmed by a roentgenogram of the wrist (lateral view in 30 degrees supination) and injection of the pisotriquetral joint with local anesthetic. Excision of the pisiform resulted in complete relief of pain.

The reaction of nerve tissue to various suture materials: A study in rabbits

Adult, male white New Zealand rabbits were used to compare two new synthetic suture materials, polyglycolic acid (Dexon) and polypropylene (Prolene), with wire, plain catgut, and silk. The purpose of the study was simply to determine the reaction of nerve tissue to each of the five different materials. No attempt was made to measure functional results. The nerves were examined grossly and microscopically in an effort to evaluate which suture incited the least host reaction. Although no difference was noted in the initial cellular response, Prolene was shown to incite the least fibrolastic response. Silk evoked the most marked fibroblastic response.

Correlation Between Muscle Morphology of the Transverse Carpal Ligament and Branching Pattern of the Motor Branch of Median Nerve

PURPOSE This was an intraoperative anatomical study to identify the prevalence of variations in the motor branch of median nerve and to correlate these with the presence of a transverse carpal ligament (TCL) with superficial or interposed muscle. METHODS Over a period of 12 years in 1400 consecutive patients in whom the carpal tunnel was opened for any reason, observations were made in each hand to (1) determine the presence or absence of muscle fibers lying superficial to or within the TCL and (2) identify the anatomic branching patterns of the motor branch of median nerve. The primary objective was to ascertain whether the appearance of the TCL could be used to predict the anatomy of the motor branch. RESULTS A normal motor branch arising beneath a purely ligamentous TCL was found in 1011 hands (72%). The focus of this paper is on the remaining 386 hands (28%), in which muscle fibers were found lying superficial to or within the TCL; in this group, only 29 hands (8%) had a normal motor branch. An anomalous motor branch was found in 93% of hands with a TCL with superficial or interposed muscle fibers and in less than 1% of hands with a purely ligamentous TCL. CONCLUSIONS In exposing the carpal tunnel, special care should be taken by the surgeon to identify and protect the motor branch when muscle fibers are encountered superficial to or within the TCL.

Radiographic Spectrum of Severity in Madelung's Deformity

PURPOSE To establish whether Madelungs deformity demonstrates a radiographic continuum of severity and whether a forme fruste does exist. METHODS Ulnar tilt, lunate subsidence, palmar carpal displacement, and lunate fossa angle were measured in 81 wrist radiographs with obvious or suspected Madelungs deformity. Statistical analyses based on these measurements were performed to ascertain if there is a deformity continuum. RESULTS Ranges of 15 degrees to 51 degrees (mean, 28 degrees) for ulnar tilt, -7 to +11 mm (mean, -0.8 mm) for lunate subsidence, 9 to 25 mm (mean, 15.3 mm) for palmar carpal displacement, and 20 degrees to 56 degrees (mean, 33 degrees) for lunate fossa angle were obtained. Significant correlations were observed between all measurements. CONCLUSIONS Madelungs deformity encompasses a spectrum of radiographic abnormality. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic I.

A transpositional skin flap for release of volar contractures of a finger at the MP joint

We describe a finger flap which, in properly selected patients, and with careful planning of the incision design, has been useful for covering small defects over the volar aspects of the MP joint. The donor site can be closed without skin grafting.

Screw Fixation Alone for Scaphoid Fracture Nonunion

Scaphoid fracture nonunion can often lead to pain, arthrosis, and disability. While typically the result of delayed diagnosis or inadequate treatment, it can sometimes occur even if the initial care was timely and appropriate. Whereas early recognition of acute fractures allows for nonoperative management, nonunions frequently require surgical treatment. Traditionally, this has involved open debridement and bone grafting. However, some publications suggest that certain stable nonunions may be amenable to percutaneous debridement and fixation without formal bone grafting. Although certain characteristics appear to be appropriate indications for such management, well-designed clinical studies are needed to better define them.