Lois Carlson

Treatment of Reflex Sympathetic Dystrophy Using the Stress-loading Program

Abstract Reflex sympathetic dystrophy (RSD) may occur following any trauma to the upper extremity. Symptoms include pain; swelling; vasomotor, sudomotor and trophic disturbances; stiffness; and decreased function. Stress-loading is presented as an effective treatment of RSD. The stress-loading program consists of active exercises that require stressful use of the upper extremity with minimal joint motion. If necessary, other modalities are used to treat the residual fibrosis that occurs secondary to RSD, only after the pain and swelling subside. A theoretical rationale for the use of stress loading in RSD is presented in light of current theories of RSD and exercise physiology. Exercise, if of sufficient intensity, duration and frequency, places a demand on tissues that causes adaptive changes. Active loading of the involved tissues in RSD provides input to the central nervous system, which is hypothesized to alter the abnormal sympathetic output and break up the pain cycle.

Use of Quantitative Abductor Pollicis Brevis Strength Testing in Patients with Carpal Tunnel Syndrome

Background: Diagnosis of carpal tunnel syndrome remains clinical, despite many objective clinical and electrophysiologic tests. There is also a need to objectively assess the severity of involvement and the need for surgery, and to document response to treatment. The authors evaluated a hand-held strength-testing device for assessment of abductor pollicis brevis strength in patients with carpal tunnel syndrome. Methods: Sixty-two hands in 50 patients (39 women and 11 men) aged 26 to 57 years were examined. All hands were evaluated before and 6 weeks after surgery. Nineteen hands were available for 7-year follow-up. Results: Abductor pollicis brevis strength following carpal tunnel release increased significantly from a mean of 2.3 kg to 3.1 kg. The strength further increased in all long-term follow-up patients. Conclusions: Quantitative strength testing can be used to document changes in abductor pollicis brevis strength in response to treatment in patients with carpal tunnel syndrome. Further study is needed to assess the reliability of this testing method using multiple examiners in patients with carpal tunnel syndrome, and to evaluate the utility of using this device in tracking the long-term outcome of patients after carpal tunnel release.

A technique for the repair of chronic volar plate avulsion of the proximal interphalangeal joint: a review of 54 cases.

Background: The authors delineate a subgroup of proximal interphalangeal joint injuries with chronic pain and limitation of movement, despite a stable joint, and describe and evaluate a surgical procedure. Methods: Through a volar approach, the volar plate is freed from scar but remains connected on either the ulnar or radial border. A new connection to the middle phalanx is established by creating a bony groove, and the volar plate is loosely attached distally. Fifty-four joints with chronic volar plate avulsion injuries of the proximal interphalangeal joint were evaluated. All patients had chronic pain and limitation of motion and function in a stable and congruent joint. Patients were examined at 6 weeks, 3 months, and 1 year after surgery. Range of motion, grip strength, and pain were evaluated. The average time to surgery was 10.5 ± 11.8 months (range, 2 to 65.4 months). The mean postoperative follow-up period was 10.0 ± 12.8 months (range, 3 to 73.5 months). Results: All patients had an improved range of motion following surgery. The difference from the preoperative range of motion was statistically significant (p < 0.0001). None of the patients reported pain on rest after surgery, and five patients reported activity pain. The mean grip strength was 32.4 ± 13.4 kg for hand that had been operated on and 41.0 ± 14 kg for the hand that had not been operated on. Conclusions: This technique for repair of chronic volar plate avulsion injuries allows early motion and results in significant improvement in range of motion, pain, and overall function in this subgroup of patients.

Long-term durability of tendon arthroplasty with excision of the trapezium in stage 1 osteoarthritis of the thumb CMC joint.

Basal joint arthritis of the thumb is commonly treated surgically. Although the results are good, there is still controversy regarding the treatment of young people with low radiographic stages of disease. Our purpose was to evaluate the durability of a tendon arthroplasty procedure in this population. Thirty patients aged 55 years or under, with early stage arthritis, were evaluated. Eight patients were available for long-term (average 86 months) follow-up. No deterioration in the strength and mobility of the operated thumbs in the long-term was found. There was a significant increase in tip pinch strength between short- and long-term follow-up evaluations. This study supports the durability of this surgery in younger patients, potentially reducing the need for multiple surgeries.

Surgical technique for the treatment of radial wrist pain

Chronic radial wrist pain with no radiographic evidence of scapholunate instability or other wrist disease can be difficult to diagnose and treat. Our purpose was to evaluate the results of an operation to treat chronic radial or periscaphoid wrist pain that has failed to respond to conservative treatment. We examined the scapholunate ligament and performed a dorsal capsulodesis. One hundred-and-two patients were reviewed retrospectively. Casenotes were available for 88 patients. Function, pain, range of movement (ROM), and grip and pinch strengths were evaluated. Twenty (23%) of the patients were found to have a scapholunate ligament tear of 0–30%, 55 (61%) had a tear of 30%–60%, and 14 (16%) had a tear of 60%–100%. Mean postoperative grip strength was 29.5 kg (80% of the normal side). Postoperative range of movement was significantly limited in flexion compared with the normal side. All patients returned to their previous employment. Seventy (80%) of the patients described improvement in pain and function. Twenty-two (25%) required further operation on the same wrist. This procedure may be indicated in patients with chronic radial wrist pain and no overt instability that is resistant to conservative treatment. It has minimal morbidity and gives good results.

A minimal wrist arthroplasty for early wrist osteoarthritis.

Background The most common forms of salvage surgery for wrist arthritis of any stage are four corner fusion and proximal row carpectomy. Younger, high demand patients with early arthritis may not be candidates for this type of salvage surgery. We describe a technique and preliminary case series of a minimal radiocarpal arthroplasty aimed at patients with initial and isolated wrist arthritis (stage 1). This procedure does not preclude any procedure that may become necessary in the future. Patients A series of nineteen male heavy laborers with scapholunate advanced collapse (SLAC grade 1-2) wrist osteoarthritis that felt the wrist arthritis was prohibiting their function enough to warrant surgery, but were unwilling to undergo a salvage procedure, were treated with the technique. The average age was 57.2 (± 7.7) years. The average follow up period was 40.3 months (9-63 months). All patients returned to heavy labor. No revision surgery was needed within the follow up period. Range of motion (ROM) and grip strength did not significantly improve. Patient satisfaction was high despite imperfect results. Conclusions Minimal arthroplasty as described may provide a temporary solution for active patients with symptomatic early wrist arthritis who are not candidates for salvage wrist surgery. Longer -term follow up as well as investigation of additional stabilization procedures is necessary.

Progression of surgical scars in the hand and wrist over time: A peak in scar-related symptoms

Abstract We have noted a peak in induration and tenderness around scars with accompanying symptoms 6–8 weeks after most hand operations. The purpose of this study was to characterise this phenomenon. All consecutive patients treated for fractures of the distal radius through a volar scar were prospectively enrolled. Exclusion criteria included: previous injuries of that wrist, no volar scar, open fractures with considerable soft tissue injury, or injuries to the nerve or vessel, or all three. Patients were evaluated every other week for three months after the operation for the following: tightness, the Vancouver scale, oedema, and range of movement in the wrist. Non-linear mixed effects models were used for analysis. Eighteen patients were evaluated. The primary outcomes included a reduction in pliability from 2.1 (0.6) to 0.9 (0.5), and subjective tightness that decreased from 3.6 (1.8) to 1.5 (2.6). Both pliability and subjective tightness showed a parabolic pattern over time, with a peak at 5.10 (95% confidence interval (CI) 4.36 to 5.84) weeks and 4.12 (2.19 to 6.05) weeks, respectively. Mean (SD) active extension increased from 22.5 (11.4)o at 2 weeks to 45.5 (13.4)o at 12 weeks. Flexion increased from 19.1 (10.2)o to 33.0 (14.7)o. Oedema decreased from 19.4 (2.1) to 17.3 (1.3) cm. The Vancouver scale decreased from 6.0 (1.9) to 3.4 (1.9), and these variables showed a consistent pattern of change over time. Our results support the existence of a peak in scar symptoms, illustrated by a reduction in pliability and an increase in subjective tightness about 4–5 weeks after the operation. Anticipating this healing pattern can aid in tailoring postoperative management of the scar.

Range of movement in the wrist as a diagnostic tool in radial-sided wrist pain

Kienböck disease is diagnosed by imaging studies, and is often difficult to diagnose in its early stages. Our clinical impression is that wrist movement is more limited in Kienböck disease than when radial-sided wrist pain is caused by other conditions. The purpose of this study was to determine the use of wrist movement in differentiating between early Kienböck disease and radial-sided sprained wrist. We retrospectively reviewed 62 cases of Kienböck disease and 49 patients with radial-sided wrist sprain. Wrist movement at presentation was recorded. The two groups differed significantly in flexion and extension (p<0.001). The ability of movement of the affected wrist relative to the normal side to distinguish between the groups was excellent (AUC = 0.96, 0.97, respectively). The ability of wrist movement measurements to differentiate between early Kienböck disease and radial-sided wrist sprain emphasises that wrist movement should be measured prior to invasive or expensive testing.

Ten-Year Minimum Follow-Up of 4-Corner Fusion for SLAC and SNAC Wrist

Background: Scapholunate advanced collapse (SLAC) of the wrist is the most common degenerative condition of the wrist. Four-corner fusion (4CF) is performed as salvage surgery, though there is limited information on its long-term results. We hypothesized that 4CF is a durable surgery with good clinical long-term function. Methods: A retrospective chart review of patients undergoing 4CF as well as an interview and recent radiographs were obtained. Patients with a follow-up period of less than 10 years were excluded. Long-term evaluation included standard wrist radiographs, wrist range of motion, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Radiographs were evaluated and described by the Kellgren-Lawrence classification. Results: Four hundred eighty-nine wrists underwent a 4CF for SLAC wrist from 1982 to 2003. Twelve patients (15 wrists) were available for follow-up. Average age at surgery was 49.1 years (range, 25-67 years). Average follow-up postsurgery was 18 years (11-27). Scapholunate advanced collapse was the etiology in 13 wrists and scaphoid nonunion advanced collapse in 2 wrists. Average extension/flexion arc was 68.6° (0°-96°), and radial/ulnar deviation arc was 32.9° (0°-5°). QuickDASH scores averaged 7.8 (range, 0-32.5), with only 1 score above 16. Seventy-three percent of radiographs showed minimal to moderate joint destruction, and 27% showed severe joint destruction. Conclusions: Scaphoid excision and 4CF remains a reliable procedure for patients with advanced wrist arthritis. Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. Patient satisfaction was high, and functional impairment was low.

Surgical treatment of synovial-collagen disorders of the hand

Critical relationships between collagen and synovium exist and affect the function of the hand. Understanding these relationships enhances the ability to perform surgery including procedures addressing soft tissue and joint pathology. We present a series of surgical procedures based on this principle.