Lawrence H. Schneider

Tuberculosis of the hand and wrist

Over the past 5 years we have encountered 11 cases of Mycobacterium tuberculosis of the hand and wrist. The most striking feature of this series was the delay between the onset of symptoms and the correct diagnosis. Many patients had a diagnosis of rheumatoid arthritis or nonspecific synovitis prior to the diagnosis of tuberculosis. There was a striking lack of pulmonary symptoms. Only two patients had a prior history of tuberculosis and only one had significant pulmonary involvement. Most had tenosynovitis involving the flexors or extensors. Three had tenosynovitis and arthritis whereas one had only tuberculous arthritis. Two patients had carpal tunnel syndrome as a result of carpal canal involvement. Ten of the 11 patients had apparent cures of tuberculosis subsequent to surgical debridement and antituberculosis therapy.

Delayed flexor tendon repair in no man's land.

Thirty-seven digital flexor tendon injuries in 31 patients were treated by closure of the skin and delayed repair from 24 hours to 21 days later. All skin wounds healed without serious complication, and there were no infections. On examination at a minimum of 4 months after repair, 36% had total active motion (TAM) of 220°, 32% from 200° to 220°, 6% from 180° to 200° and 26% with less than 180°. Under proper conditions, repair of flexor tendons can be carried out with the expectation of results comparable to more complex reconstruction procedures.

Revision of the ununited one-bone forearm

Between 1975 and 1995, 7 patients were surgically treated for persistent forearm pain following previously unsuccessful attempts of constructing a radioulnar synostosis using interosseous bone grafting with either cross screw or pin fixation. These prior reconstructive procedures were salvage operations to address symptomatic radioulnar instability. The time interval between index operation and revision surgery was a mean of 12.6 months (range, 4-36 months). The postoperative follow-up period averaged 29.7 months (range, 11-61 months). To address these failed radioulnar arthrodeses, plate osteosynthesis and aggressive bone grafting were used in 5 of 7 patients (group 1) (4 with autologous graft and 1 with demineralized bone matrix). Union was achieved in all 5 patients after a single revision operation. Radiographic evidence of solid union was seen at approximately 4 months. In the remaining 2 patients (group 2), revision synostosis procedures were performed; these involved local bone grafting and repeat transverse screw fixation in 1 patient and iliac crest bone grafting alone in the other. One of these 2 patients progressed to union; the other had a persistent symptomatic fibrous union. The 5 patients in group 1 reported symptomatic relief, while the 2 patients in group 2 were dissatisfied. There were no postoperative complications in our series. Based on our findings, we advocate abundant bone grafting and plating for rigid internal fixation in failed radioulnar synostosis procedures.

Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer

Fourteen patients were treated by flexor digitorum superficialis transfer for irreparable flexor pollicis longus lesions. Results measured by return of interphalangeal joint motion were good in 12 patients, with one patient achieving a fair result and one failure. This is a reliable procedure in thumbs with a grade I or II (Boyes) tendon bed and should be considered as an alternative to free tendon grafting for reconstruction in patients in whom return of interphalangeal motion is desirable.

Fractures of the distal phalanx

Fractures of the distal phalanx, except for those of the articular surface, are sustained in crushing injuries and as such require care for the surrounding soft tissues and rarely need specific treatment for the fracture itself. Displaced articular fractures on the palmar side, however, are associated with avulsion of the flexor digitorum profundus tendon and will need careful replacement by surgical means. While there is some disagreement among authorities, it is believed here that the dorsal articular fracture, the mallet fracture, can and should be treated by nonoperative means.

RUSSE BONE GRAFT FOR SCAPHOID NONUNION

Progressive degenerative osteoarthritis has been shown to result from the untreated scaphoid nonunion. Volar inlay-bone grafting, as described by Russe, will result in union in 85% to 90% of patients. The volar approach is simple, protects the vascularity of the scaphoid, and provides an excellent source of graft material from the distal radius. Contraindications to bone grafting include significant periscaphoid arthritis changes and a small avascular proximal pole.

Flexor tendon grafting

With continuing improvement in the results obtained from early direct repair of flexor tendon injuries there are only rare occasions when one-stage flexor tendon grafts will be needed. When indicated in minimally scarred situations, careful attention to technical details and closely supervised postoperative care will yield good return of function.

Scaphoid nonunion: An indication for wrist arthrodesis

Arthrodesis of the wrist is no longer a common choice among operations used in treatment for nonunion of the carpal scaphoid. However, there is, even in these advanced times, an indication for this reliable operation for the patient with a scaphoid nonunion complicated by symptomatic radioscaphoid arthritis. For this patient who has disabling pain that interferes with function, this procedure will provide painless stability and strength in a predictable manner.