Houshang Seradge

In vivo measurement of carpal tunnel pressure in the functioning hand

We recorded directly the pressure within the carpal tunnel during nine different functional positions of the hand and wrist in 102 hands of 92 subjects. Carpal tunnel syndrome was present in 81 hands, and 21 served as controls. A significant rise in pressure was recorded not only with wrist flexion but also with wrist extension, making a fist, holding objects, and isolated isometric flexion of a finger against resistance. Intratunnel pressure dropped after 1 minute of hand and wrist exercises and remained below the resting pressure for over 15 minutes of continuous measurement. We did not observe a rebound phenomenon. Clinical Application: Non-surgical treatment of carpal tunnel syndrome should also include a significant reduction in making a fist, holding objects, pushing, and isolated finger work such as key punching and typing. Activities that require sustained contracture of finger flexor muscles (eg, grasp and hold) also should be avoided. Brief intermittent wrist and hand exercise is recommended to reduce the intratunnel pressure.

Reduction flexor tenoplasty: Treatment of stenosing flexor tenosynovitis distal to the first pulley

Trigger finger due to stenosing flexor tenosynovitis distal to the first annular pulley is not a common finding; however, when present, it introduces a diagnostic and therapeutic challenge. Resection of the second annular pulley for release of triggering at this level may leave the patient with impaired function. The pulley can be preserved by removing an elliptical portion of the center of the tendon through a lateral incision.

Segmental motion of the proximal carpal row: Their global effect on the wrist motion

The contribution of the scapho-lunate and luno-triquetral joints to global wrist motion was studied in 11 fresh-frozen cadaver specimens. The carpus were labeled with metallic markers and the joints were selectively transfixed with wires. The wrist was allowed to follow its natural radial and ulnar deviation during flexion and extension, extension and flexion during radial and ulnar deviation, respectively. The data was collected by means of radiography, goniometric measurement, and computer analysis. The proximal carpal row (the intercalated segment) although anatomically represented as a row, presented through its two intersegmental joints, a definite segmental behavior. Each intersegmental joint of the proximal carpal row influenced global wrist motion in all directions but to a different degree for each plane of motion. The segmental joints within the intercalated segment collectively govern 40% of the wrist flexion, 33% of extension, and 10% of ulnar deviation. The scaphoid through its scapho-lunate link exerts a governing effect on total intersegmental proximal carpal row contribution to the global wrist motion.

Cubital tunnel release with medial epicondylectomy factors influencing the outcome

From 347 cases of documented cubital tunnel syndrome, 160 required cubital tunnel release and medial epicondylectomy over a 10-year period and were considered for this retrospective study. These patients were monitored for 3 years after surgery. According to the modified scale of McGowan, 86% of patients were considered stage II. Eighty-one percent of the patients were symptom free, and 96% of the patients improved by 1 Wilson and Krout grade following surgery. We considered return of symptoms 3 months or longer after surgery as recurrence; there were 21 recurrences. There was no correlation between recurrence and limb dominance, patient age at the time of surgery, or length of preoperative conservative treatment. Of the patients with recurrences, 44% were in their fourth decade of life. The rate of recurrence in females (18%) was almost twice that in males (10%). The rate of recurrence was increased twofold when the patient did not return to work within 3 months. When concomitant ipsilateral carpal tunnel was present (44%), the recurrence rate was 17% compared with 9% in those without carpal tunnel syndrome. The recurrence rate was 20% when ipsilateral thoracic outlet syndrome was present compared with 9% in patients without other ipsilateral maladies. Therefore, higher recurrence rates should be anticipated in female patients, in patients with concomitant ipsilateral thoracic outlet syndrome and/or carpal tunnel syndrome, in patients in their third or fourth decade of life, or in patients not returning to work within 3 months after surgery.

The effect of intercarpal joint motion on wrist motion: are there key joints? An in vitro study

The contribution of each intercarpal joint individually and as a member of a regional group to total wrist motion was analyzed in 10 fresh, frozen cadaver specimens. Each intercarpal joint had an effect on the total wrist motion, but the contribution of each to the different planes of motion was not equal. The scaphoid-capitate joint had a governing effect on the motion of a region comprised of scaphoid-trapezium, scaphoid-trapezoid, and scaphoid-capitate. The lunate-capitate joint had a governing effect on the motion of a region comprised of the lunate-triquetrum, lunate-capitate, triquetrum-hamate, and hamate-capitate complex. Elimination of motion in either of the key governing joints affected total wrist motion the same as elimination of motion in all the joints in that region. Intercarpal fusion for treatment of ligament injury of the proximal intercarpal row may be limited to the scaphoid-capitate or lunate-capitate joint. There is no need to attempt fusion in all joints of either of the two regions.

Median innervated hypothenar muscle: anomalous branch of median nerve in the carpal tunnel.

A hypothenar motor branch of the median nerve in the carpal tunnel was observed and its motor function was documented by direct intraoperative nerve stimulation in two patients having carpal tunnel releases. The hypothenar branch left the median nerve at the midcarpal tunnel area. It crossed the tunnel superficial to the flexor tendons and penetrated the transverse carpal ligament ulnarly to innervate the abductor digiti quinti. Such branching of the median nerve at this level has not been reported previously. Good visualization of the carpal tunnel and careful dissection of its content even in the so called safe zone ulnar to long axis of palmaris longus tendon is recommended.

Anatomical Variation of the Posterior Interosseous Nerve: A Cadaver Dissection Study

An anatomical variation of the posterior interosseous nerve was found in a cadaver. The posterior interosseous nerve entered the supinator muscle 3 cm distal to the radiohumeral joint, but exited from two sites. Fifty percent of the nerve exited under the distal edge of the supinator muscle. The other 50% of the nerve pierced through the supinator muscle, 4.2 cm distal to the articular surface of the radial head and then joined the remaining posterior interosseous nerve as it emerged from the supinator muscle distally. Variations were not found concerning the order and the manner of branches to the muscles. This variation in the posterior interosseous nerve could be an additional compression site for this nerve and therefore responsible for some of the atypical presentations of symptoms and for partial recovery after surgical decompression. Careful surgical dissection is recommended to avoid injury to this branch.

FREE VASCULARIZED TEMPORAL PARIETAL FLAP IN HAND SURGERY

Free vascularized temporo-parietal fascia (TPF) flap is a flap of thin, pliable and vascularized tissue which can cover an area measuring up to 12 cm x 14 cm. The flap is harvested based on temporal vessels, which provide a smooth, gliding surface for tendon function and eliminates the need for secondary procedures usually required by the pedicled or bulky free vascularized myocutaneous flaps. The donor pedicle is long and consistent with an average diameter of 3 mm in adults. This flap is versatile. In 12 resurfacings for traumatic wounds of hand and wrist, no flaps were lost. Donor site morbidity, except for a transient sideburn hair loss in one case, was not encountered. We recommend this flap as a viable one-stage procedure for coverage of complex hand wounds.

The reverse flexor carpi ulnaris and ulnar nerve neuropathy

Received for publication Nov. 8, 1989; accepted in revised form Nov. 6, 1991. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Houshang Seradge, MD, The Hand Center of Oklahoma, 1044 S.W. 44th, Suite 620, Oklahoma City, OK 73109. C ompressive neuropathy of the ulnar nerve in Guyon’s canal due to anomalous musculotendinous structures is well documented.‘-4 Although anomalies of the flexor carpi ulnaris (FCU) are unusual, variations at both its origin from the medial aspect of the trochlea5. 6 and its insertion*. 5. ’ have been reported. 3/l/35809 There has also been a report of a small accessory muscle

Arterial reconstruction in treatment of non-traumatic ischemia of the fingers and hand:

A non-traumatic arterial flow disruption due to thrombosis or emboli in the fingers or the hand can cause ischemic and/or trophic changes. We would like to present our 15-year experience with vein graft reconstruction of these disabling lesions. We have treated 36 patients with non-traumatic arterial flow disruption to the hands or fingers. Symptoms varied from cold intolerance to active pain and ulceration. Patients with normal flow and spastic vascular disease were excluded from this study. Over one half of the patients were smokers. Ten patients had thrombosis secondary to hammer hand syndrome. Twelve patients had radial artery aneurysms primary and/or secondary to surgery and arterial catheterizations. Two patients had ischemic hands secondary to an episode of cardiogenic shock. Four patients had thrombosed aneurysms of the thumb ulnar digital artery. Eight patients had combined digital and wrist vascular obstruction with some distal run off. Thirty-six patients required surgical treatment. Ten patients had resection with primary repair. Four patients had resection with vein graft reconstruction of ulnar artery. Four aneurysms of the thumb ulnar digital artery were treated with resection and reconstruction with vein graft. One patient underwent reconstruction of a thrombosed ulnar artery, volar arch and common digital artery. One patient had thrombosis of the radial artery, dorsal and volar arches and a digital thrombosis which were resected and reconstructed with vein graft. One patient had amputation due to poor run off. Seven patients had digital artery reconstructions with vein grafts. Two patients died from unrelated causes. Four patients developed thrombosis of the ulnar artery with reduced cold tolerance and the remaining patients were symptom free. Microvascular reconstruction of the arterial system in the hand and fingers for impending ulceration and cold intolerance is a worthwhile and rewarding procedure. Priority should be given to this procedure before considering a digital sympathectomy.