Leonard K. Ruby

The natural history of scaphoid non-union. A review of fifty-five cases.

We reviewed the cases of fifty-six scaphoid non-unions in fifty-five patients, none of whom had received treatment of any kind before examination. In the thirty-two patients who had been injured five years or more earlier, arthritis developed in thirty-one (97 per cent). The one patient in whom osteoarthritis developed less than four years after injury also had avascular necrosis of the scaphoid. The incidence of osteoarthritis increased with time after injury. We concluded that patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop.

Intraosseous blood supply of the capitate and its correlation with aseptic necrosis

Isolated capitate fractures that result in the development of aseptic necrosis of the proximal pole are uncommon. Five patients were treated who developed aseptic necrosis of the proximal pole. Four had a history of trauma with radiographic evidence of nonunion. In vitro arterial injection studies were done to correlate clinical problem with intraosseous capitate vascularity. Palmar vessels were found to contribute the majority of the blood supply to the capitate. Three patterns of intraosseous blood supply were seen. In each pattern, the proximal pole received its blood supply exclusively in a retrograde fashion across the capitate waist analogous to the proximal scaphoid. Aseptic necrosis without collapse of the proximal pole was successfully managed with curettage and bone grafting in three patients. The remaining two patients, with collapse and pericapitate degenerative changes, were managed with intercarpal fusion.

Ulnar styloid impaction syndrome

A series of 8 patients each with an excessively long ulnar styloid that was impacting the triquetrum, causing chondromalacia, synovitis, and pain, is presented. Four patients developed symptoms as a result of an injury and 4 had no definable acute precipitating injury. The average age at the time of surgery was 34 years. There were 3 male and 5 female patients. The average follow-up period was 34 months. All patients were treated by open partial ulnar styloidectomy. Outcome was evaluated clinically and by means of patient questionnaire and radiographs. Pain decreased from a preoperative average score of 3.5 to a postoperative average score of 1.3, which equates to mild pain requiring no medication. All but 1 patient returned to their previous employment unrestricted. The average preoperative ulnar styloid length was 7.4 mm and the average ulnar styloid process index was 0.41, which is almost twice normal. There were no complications. It is likely that an excessively long ulnar styloid has important implications for the kinematics of the lunatotriquetral interval. Details of the diagnosis of this condition, including a new provocative test, and operative management are discussed.

A critical look at intercarpal arthrodesis: Review of the literature

Painful joints have long been treated by arthrodesis. Limited intercarpal arthrodesis as an alternative to total wrist arthrodesis began gaining popularity in the late 1960s. Peterson and Lipscomb described various combinations of intercarpal arthrodeses for painful conditions affecting selected carpal bones.~ The authors concluded that these limited wrist artha-odeses rclieved pain while providing stability and preserving motion. Since that time, many different limited intercarpal arthrodesis combinations have been described in the literature; these include the scaphotrapezium trapezoid, lunottiquetral, scapholuhate, scaphocapitolunate, scaphocapitate, capitolunate, and capitohamate-lunotriquetral arthrodeses. They are described for various indications such as intercarpal arthrosis and instability, but pain is the most conunon indication. Postoperative results have varied. We were interested in reviewing the reported data on intercarpal arflarodesis to obtain a clearer understanding of the outcomes of each type of arthrodesis and how the different t ~ e s compared in terms of nonunion, rate of other complications, postoperative grip strength, range of motion (ROM), and pain relief. We examined the limited intercarpal

Attempted scapholunate arthrodesis for chronic scapholunate dissociation

We report a retrospective review of seven patients with chronic scapholunate dissociation treated with attempted scapholunate arthrodesis. All procedures were done between 1978 to 1983 by one surgeon. Seven patients with follow-up of nine months or greater were available for review. Follow-up for the four patients with successful operations averaged seventy-seven months. Average age was 34 years (range from 19 to 46). Only one patient demonstrated radiographic fusion. Of the remaining six patients, three had no further wrist pain. The other three operations were total failures requiring other procedures for pain relief. For all patients, flexion-extension are decreased an average of 4 degrees. Grip strength averaged 88% of the unaffected side. Lateral scapholunate angle improved from an average preoperative angle of 70 degrees to a postoperative angle of 59 degrees. We conclude that this procedure is not a predictable method to treat scapholunate dissociation.

The pronator quadratus interposition transfer: An adjunct to resection arthroplasty of the distal radioulnar joint

Ulnar head resection for treatment of painful traumatic and arthritic conditions of the distal radioulnar joint has been performed for over 100 years. Although this is a time-honored procedure, several negative sequelae of the operation have been described. Most of these problems have been due to the instability of the ulna remnant with respect to surrounding structures, including the radius and extensor tendons. This report describes an operative technique to prevent and treat this problem. The pronator quadratus origin is transferred to the dorsum of the ulna, placing the muscle belly between the radius and the ulna remnant. Theoretically, this may provide a soft tissue cushion to prevent ulnoradial impingement. We have been performing this operation since 1985 and report here the results on 16 wrists in 15 patients who underwent surgery between 1985 and 1989. Patients included in this study had pain in the distal radioulnar joint due to osteoarthritis, post-traumatic arthritis, or incongruity. No patients with rheumatoid or other autoimmune arthritis were included. The average follow-up period was 8 years, with a range of 5-9 years. Two groups of patients were studied, including seven who had failure of prior ulna head resection and eight who underwent this procedure (one on both wrists) concomitantly with ulnar head resection.

Osteoid osteoma of the hand

A review of all cases of osteoid osteoma of the hand seen by four hand surgeons over the last 10 years was performed. Seven cases were documented. Average follow-up was 28.3 months. Average age of the patients was 21.1 years. Five men and two women participated. Six lesions were in the right and one in the left upper extremity. Delay from presenting symptoms to definitive treatment averaged 13.5 months with a range of 7 to 30 months. Surgical excision was curative in all cases. We concluded that although a very unusual occurrence, osteoid osteoma of the hand should be considered in the differential diagnosis of pain in the hand.

Results of extensor carpi ulnaris tenodesis in the rheumatoid wrist undergoing a distal ulnar excision

Distal ulna resections that are done in patients with rheumatoid arthritis to alleviate pain, correct alignment, and prevent tendon rupture may contribute to distal ulnar instability. A distally based slip of the extensor carpi ulnaris tendon has been used to both stabilize the distal ulnar remnant and to prevent recurrent deformity in 26 rheumatoid wrists, with an average follow-up of 3.5 years. In all postoperative cases, the distal ulna was no longer prominent and the wrist was well aligned. The distal ulna was stabilized in 96% of the patients. Subjectively, pain was relieved in 85% and grip strength improved in 77%.

Coverage of a carpal tunnel wound dehiscence with the abductor digiti minimi muscle flap

A 41-year-old man who was taking 60 mg of prednisone a day for dermatomyositis developed a wound dehiscence following a carpal tunnel release and flexor tenosynovectomy. Coverage of the exposed carpal contents was provided by using the abductor digiti minimi as a local transposition flap.

Median nerve compression neuropathy by the lacertus fibrosus: Report of three cases

Three patients exhibiting acute onset of proximal forearm pain and muscle weakness are reviewed. After nonoperative therapy failed, surgical exploration revealed compression of the median nerve at the level of the lacertus fibrosus. All three patients experienced complete recovery after release of the lacertus fibrosus.