Edward A. Nalebuff

Arthrodesis of the Rheumatoid Wrist: An Evaluation Of Sixty Patients And A Description Of A Different Surgical Technique

In a series of sixty patients (seventy arthrodeses) a technique was developed in which freshened bone surfaces of the carpus and radius were coapted and immobilized by an intramedullary pin, supplemented as needed by staples or a Kirschner wire. Fusion was successful in all but two patients and all patients benefited by increased strength and function in the hand. The advantages of the operation are: short operating time, so that other procedures can be done concomitantly, and a short recuperation time, so that activity, such as walking with crutches, is not lost.

Flexor tendon ruptures in patients with rheumatoid arthritis

One hundred fifteen flexor tendon ruptures were reviewed in 43 hands with rheumatoid arthritis, one hand with psoriatic arthritis, and one hand with lupus erythematosis. Ninety-one tendons were ruptured at the wrist, four ruptures occurred at the palm, and 20 ruptures occurred within the digits. At the wrist level, 61 ruptures were caused by attrition on a bone spur and 30 were caused by direct invasion of the tendon by tenosynovium. All ruptures distal to the wrist were caused by invasion of the tendon by tenosynovium. Patients whose ruptures were caused by attrition regained better motion than those whose ruptures were caused by invasion by tenosynovitis; however, motion overall was poor. Patients with isolated ruptures in the palm or at the wrist had the best functional results. Those patients with multiple ruptures within the carpal canal had a worse prognosis. Ruptures of both tendons within the fibro-osseous canal had the worst prognosis. The severity of the patients disease and the degree of articular involvement had a great effect on the outcome of surgery. Prevention of tendon ruptures by early tenosynovectomy and removal of bone spurs should be the cornerstone of treatment.

Arthroplasty of the rheumatoid wrist with silicone rubber: An early evaluation

A review of the results of 37 arthroplasties of the wrist with flexible silicone, done at least 6 months before, in patients with rheumatoid arthritis showed six (16%) to have residual discomfort and two (5%) to have recurrent deformity. Pain was the primary indication for treatment in 31 and deformity in six. Three of 37 wrists had prosthetic fractures (8%). Ten patients who had the opposite wrist fused before the arthroplasty felt the movable wrist was more functional. Contraindications are marked deformity, significant instability, excessive bone loss, and multiple tendon ruptures.

Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow.

Decompression of the ulnar nerve at the elbow with medial epicondylectomy was done in 43 patients and reviewed with an average follow-up of 2.3 years. Eight were graded as excellent, 23 as good, 9 as fair, and 3 as poor results. A special emphasis was placed on analysis of the potential disadvantages of medial epicondylectomy including bone tenderness at the osteotomy site, vulnerability of the ulnar nerve, ulnar collateral ligament instability, and weakness from disruption of the flexor pronator origin. Clinical assessment of strength including quantitative measurement of pinch strength, grip strength and endurance, and testing of forearm muscles did not show these potential disadvantages to be significant problems.

Dislocation of the distal radioulnar joint: anatomy and clues to prompt diagnosis.

The articular disk is a strong, complex structure responsible for the stability of the distal radioulnar joint. It is injured by a hyperpronation or hypersupination injury which disrupts the disk or its strong central attachment to the ulna. Prompt diagnosis is essential for a good result as no good late reconstruction is available. Reliance on radiographs for the diagnosis will seldom be rewarding, and they are mainly of value in ruling out associated fractures. A careful clinical examination and a high index of suspicion are the best tools available for diagnosis in this injury.

Volar Transnavicular Perilunar Dislocation of the Carpus

A case history of an extremely rare volar perilunar dislocation of the carpus with fracture of the navicular has been presented. The mechanism of injury in this patient was a force directed to the dorsum of the partially flexed hand. This fracture-dislocation presents the reverse picture of the more common dorsal perilunar dislocation. Our explanation of the mechanism of the production of lunar and perilunar dislocation is presented.

Posterior Interosseous Nerve Syndrome Secondary to Rheumatoid Synovitis

Three additional cases of posterior interosseous-nerve paralysis secondary to rheumatoid arthritis were seen. All were initially diagnosed as extensor tendon ruptures and in one patient the extensor tendons were explored before proper diagnosis was made. The condition is a compression neuritis of the posterior interosseous nerve secondary to elbow synovitis bulging anteriorly against the overlying supinator muscle. Treatment by injection of steroids was successful in one patient; synovectomy cured the condition in the second; and a tendon transfer was used in the third.

Rupture of the radial collateral ligament of a metacarpophalangeal joint to one of the ulnar three fingers

In six patients rupture of the radial collateral ligament of the metacarpophalangeal joint of one of the three ulnar fingers, surgical reconstruction was successful using local tissues in five and a tendon graft in one. Operative treatment of this injury is indicated only when significant instability is present.

Rupture of the flexor tendons of the index finger after Colles' fracture. Case report

Delayed rupture of a tendon at the wrist secondary to a Colles’ fracture is very rare. Nevertheless, it has been well documented in the literature, especially with reference to the tendon of the extensor pollicis bongus. Boyes and associates showed that rupture of the flexor tendons of the fingers occurs less often than rupture of the extensors, and in their series of eighty cases only two followed fracture of the radius. Two other such cases were reported, and in all of the four reported cases there was a considerable delay between the injury to the bone and the rupture of the tendon. The case reported here is one of rupture of the long flexors of the index finger which occurred soon after a fracture of the radius.

Injury to the Deep Motor Branch of the Ulnar Nerve During Carpal Tunnel Release

Complications following carpal tunnel release have been reported to occur in 12-20%’ of cases and are numerous and varied. Neurologic complications that have been reported usually involve the palmar cutaneous or motor branch of the median nerve.’ Ulnar nerve injury during carpal tunnel release has been reported rarely. The only cases reported include cases of injury to the main ulnar palmar cutaneous nerve,* the ramus communicans3 (a normal sensory communication between the ulnar and median nerve in the palm), and a partial ulnar nerve injury in Guyon’s cana1.4 We have encountered three cases of injury to the deep motor branch of the ulnar nerve just distal to the hook of the hamate in the midpalmar space. All injuries occurred during routine carpal tunnel release performed by experienced orthopaedic surgeons and were not appreciated intraoperatively. Case Reports