M. Gabl

Finger injuries in extreme rock climbers. Assessment of high-resolution ultrasonography.

Dynamic high-resolution ultrasonography findings obtained in 34 extreme rock climbers with finger injuries were compared with those in 20 healthy volunteers. Thicknesses of the flexor tendon and A-2 flexor tendon pulley system were measured at the base of the proximal phalanx. The distance between the tendon and phalanx was evaluated with the finger in extension and in forced flexion as a measure of bowstringing. Gliding ability of the flexor tendons was assessed during active and passive motion. Compared with healthy volunteers, climbers showed a significantly increased thickness of the flexor tendons and the flexor tendon pulley system but no impairment of the gliding mechanism. Only in climbers did the distance between tendon and phalanx increase from 0.14 cm ( 0.07) during extension to 0.30 cm ( 0.09) during forced flexion. In three climbers with complete A-2 pulley ruptures this distance was up to 0.51 cm ( 0.15) during forced flexion. Clinically unsuspected synovial cysts, thickened joint capsules, fibrous tissue, or fluid collection were found only in climbers. We concluded that dynamic ultrasonography is a valuable tool for accurate assessment of early changes in “climbers finger.” It provides useful information, especially in cases where clinical evaluation is difficult, and should be performed to select appropriate therapeutic management.

Closed reduction transarticular Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett's fracture dislocation.

Thirty two patients with fracture dislocations of the base of the thumb metacarpal with a single large fracture fragment (Bennett’s fracture) were either treated by open reduction and internal fixation or closed reduction and percutaneous transarticular Kirschner wiring. All were assessed at a mean follow up of 7 (range 3–18) years. Patients with an articular step off more than 1 mm were excluded. The type of treatment did not influence the clinical outcome or the prevalence of radiological post-traumatic arthritis. The percutaneous group had a significantly higher incidence of adduction deformity of the first metacarpal. This was attributed to Kirschner wire placement near the fracture line or in the compression zone of the fracture, resulting in loss of reduction. This however did not result in an inferior outcome.

The Use of a Graft from the Second Extensor Compartment to Reconstruct the A2 Flexor Pulley in the Long Finger

A 10 mm wide ring graft from the second extensor compartment with periosteum from the floor of the sheath was used to correct bowstringing in six patients who sustained an isolated rupture of the A2 pulley. It was attached to the lateral rims of the sheath. Periosteum was used for additional graft fixation. Bowstringing was assessed by magnetic resonance imaging and ultrasound preoperatively and 19.5 months after surgery. It was corrected in five patients and improved in one. Pain was reduced from 35 to 7 points on a visual analogue scale. Digital circumference decreased from 76 to 71 mm. Flexion at the PIP joint increased from 88° to 116°. Pinch grip improved from 28 to 56 N.

Reconstruction of the digital flexor pulley system: A retrospective comparison of two methods of treatment

The rare injury of closed rupture of the A2 and A3 flexor pulleys was treated using two non-encircling techniques of pulley reconstruction. Thirteen patients were treated with an extensor retinaculum graft (Group A). At a mean follow-up time of 48 months, the average PIP flexion was 97%, the power grip strength 96%, the pinch grip strength 100% and the thickening 94% of the uninjured side. Ten patients were treated with a free palmaris longus tendon grafts (Group B). At a mean follow-up time of 57 months, the average PIP flexion was 94%, the power grip strength 98%, the pinch grip strength 100% and the thickening 95% of the uninjured side. In both groups, finger extension was unrestricted. The Buck Gramcko score included 10 excellent, two good and one fair result in Group A and seven excellent, two good and one fair result in Group B. Both techniques proved beneficial. All climbers returned to their previous standard and all non-climbers regained full finger dexterity in their previous job.

The interosseous membrane and its influence on the distal radioulnar joint: An anatomical investigation of the distal tract

From the interosseous membrane of the forearm a tract extends to the dorsal capsule of the distal radioulnar joint. The structure and function of this tract have been investigated. The tract originates from the radius 22 mm proximal to the distal dorsal corner of the sigmoid notch. Central fibres are attached there with fibrous cartilage and superficial bundles mix with the periosteum. The tract is 8 mm wide, 31 mm long and 1 mm thick. Distally it inserts at the capsule of the distal radioulnar joint between the tendon sheaths of extensor digiti minimi and extensor carpi ulnaris. Deep fibres insert directly at the triangular fibrocartilage. The tract of the interosseous membrane is taut in pronation and loose in supination. It strengthens the dorsal capsule of the distal radioulnar joint. During pronation the tract protects the ulnar head in a sling. Its attachment at the triangular fibrocartilage influences the distal radioulnar joint. Its insertion at the triangular fibrocartilage and the support of the weakest part of the dorsal capsule are of interest.

The Role of Dynamic Magnetic Resonance Imaging in the Detection of Lesions of the Ulnocarpal Complex

A prospective study of 32 patients was carried out to investigate the significance of dynamic magnetic resonance imaging (MRI) in diagnosis of triangular fibrocartilage (TFC) lesions. Tears of the TFC can be diagnosed well by means of static MRI and arthroscopy. Dynamic MRI examination has an advantage in evaluating the stability of the TFC and ulnocarpal impingement. By means of dynamic MRI it was possible to make a preoperative diagnosis of an ulnocarpal impingement in five patients, a diagnosis which was confirmed through arthroscopy in all cases. In three further patients, dynamic MRI showed ulnocarpal impingement caused by instability of the ulnar attachment of the TFC. This kind of impingement could not be ascertained arthroscopically. Dynamic MRI extends the possibilities of evaluating obscure ulnar wrist pain. Its significance lies in the non-invasive examination of ulnocarpal impingement as well as the evaluation of TFC stability.

Distal Radius Fractures and Concomitant Injuries: Experimental Studies Concerning Pathomechanisms

Since Colles’ description of the distal radius fracture (1814) and the publication by Dupuytren (1834), the frequency of this fracture, and the problems associated with it, have been increasingly recognized. Not only the treatment but also the mechanism of injury of the different types of fracture have been analysed repeatedly. The various theories concerning the pathomechanism have led to names such as “sprain fracture”, “bent fracture”, “thrust fracture”, “compression fracture”, “snap fracture” and others. In our experimental studies, we attempted to simulate the pathomechanics of distal radius fractures, and to represent it illustratively. With the aid of a materials testing machine, 63 prepared cadaver parts were hyperextended at the wrist joint until distal radial fracture occurred. Accompanying injuries were identified radiologically and by dissection. Furthermore, the cadaver parts were deep-frozen and examined by means of computer tomography and cryo-section, using Kathrein’s method. Through experimental hyperextension, it was possible to generate dorsal, central and palmar types of fracture. We produced 42 dorsal, 14 central and seven palmar fractures. The extent to which the carpal bones of the proximal row were pressed against the dorsal or palmar edge; or the centre of the distal radial articular surface, was fundamental. Subsequent dissection showed multiple concomitant injuries in 40 cases (63%), and none in 23 cases (37%). One reason for the occurrence of such concomitant injuries may be the relative strengths of the bone and ligaments. Most frequently (27 cases, or 43%), we found a destabilization of the triangular fibrocartilage, with or without a bony avulsion fragment (fracture of the ulnar styloid process), followed by ruptures of the interosseous ligaments between the scaphoid and the lunate (20 cases, or 32%) and between the lunate and triquetrum (11 cases, or 18%). The application of knowledge gained from experimental studies carried out on fixed cadaver parts to clinical cases is problematic. This holds true for both concomitant injuries and fracture types. The lack of physiological defence reflexes as well as the deliberately slowed experimental procedure must be taken into account. On the other hand, in this series of experiments it was possible to generate experimentally many of the radius fractures found in clinical practice, together with their concomitant injuries.

Musculosceletal Reconstruction in Bilateral Forearm Transplantation

BACKGROUND Improvement of motor function of the upper extremity was investigated in a patient following bilateral forearm transplantation. PATIENTS AND METHODS Following an electric shock injury with amputation of both forearms at the proximal level a bilateral allotransplantation was performed 2003 in a 41-year-old male patient. Missing and insufficient muscles were replaced by donor units. For use of myoprothesis in case of transplant failure remnants of BR, ECRL, ECRB and ECU remained at the recipient. 3.5 mm DCP plating was used without bone grafting to stabilize the forearm bones. PT, FCR, FDS, PL of the donor was fixed to the medial epicondyle of the humerus, ECU and EDC to the periosteum of the ulna. FCU, BR, ECRL; ECRB of the donor were sutured to the corresponding fascia of the recipient muscles. For motor function NIA; NIP and the motor branches of the median nerve for PT, FCR, FDS, PL were coapted. The ulnar nerve was coapted distally to the motor branch for the FCU. Following induction therapy today IS consist of tacrolimus (trough level 8 ng/ml), everolimus (trough level 6 ng/ml) und Prednisone (5 mg/day). RESULTS Both grafts are vital at FU of 6 years and 1 month. During the first 3 years episodes of graft rejection, opportunistic infection and transient metabolic disorder occurred which could be treated successfully by systemic, topical agents and change of IS. Bone healing appeared normal. TRM of the upper extremity improved from 32.7% before surgery to 74.6% of normal, with gain of wrist motion/forearm rotation of 8.7% and finger motion of 33, and 2%. The moderate muscle power (M4/5) of the deep flexors, the extensors and the intrinsic muscles is considered to be due to the long distance of reinnervation, a pre-existing electric damage to the nerv and repeated rejection episodes. CONCLUSION Range of motion of the upper extremity improved primarily by extrinsic muscle function. Muscle strength and grip are moderate. The patient described the following to be most beneficial: the better range of motion, the possibility to perform tasks without visual control, the availability of his range of motion 24 h a day and a new sense of body integrity.

Isolated rupture of the finger flexor pulley system

Dislocation of the extensor tendon over the metacarpophalangeal (MP) joint is a rare problem in patients without rheumatoid disorders. We reviewed 30 cases to provide insight into the pathoanatomy of extensor tendon dislocation over the MP joint and a rational approach to the treatment of this disorder. Between 1982 and 1994, 30 patients with dislocation of the extensor tendon were treated at our institution. Nineteen patients had traumatic dislocation, seven had spontaneous dislocations, and four had congenital dislocations. Single-digit involvement was present in 25 patients, and multiple-digit involvement was present in the remaining five patients. The long finger was most frequently affected (18 digits). The other fingers were affected almost equally. Displacement of the extensor tendon always occurred in the ulnar direction in the long and ring fingers. The index and little fingers exhibited different patterns of dislocation; two patients had ulnar dislocation of both the common and proprius tendons, and the remaining five patients had divergent dislocation of the two tendons. Nonsurgical treatment was undertaken in seven cases. Surgery was performed in 23 cases. Follow-up of all cases was conducted in an average of 26 months. There were no recurrent dislocations of the extensor tendon in any patients. All the patients had full range of motion and were free of symptoms. Two patients complained of a conspicuous surgical scar. Based on our experience, patients seen within 2 weeks of injury initially should be treated with splinting of the involved MP joint in neutral position. Chronic dislocations should be treated with a primary repair of the defect in the sagittal band. When the sagittal band is absent or deficient, the tendon must be stabilized using a loop procedure with a slip of the EDC tendon.

Microsurgical reconstruction of the scaphoid and lunate bones with small, free vascularized iliac crest bone grafts

Abstract. The primary surgical goal in repairing a scaphoid nonunion, particularly one associated with avascular fragments, or reconstructing the lunate is to prevent progressive carpal collapse. In patients with persistent nonunion of the scaphoid and progressive aseptic necrosis of the lunate bone, reconstruction can be managed with a small microvascular iliac crest bone transfer. This retrospective study reports on the anatomical fundamentals, the operative procedure (particularly the harvesting of the bone flap and microsurgery), the assessment of the viability of the bone graft and the postoperative results in 80 out of a total of 210 patients on whom the surgery had been performed. From 1985 until 1998, 210 carpal bone reconstructions (134 scaphoid bones and 76 lunate bones) were performed using small, free vascularized iliac crest bone grafts. Of these, 80 patients were preoperatively evaluated and postoperatively followed up clinically and by means of conventional radiography and magnetic resonance imaging (MRI). The total rate of viability and bony union was 91.2%. This means a bone flap loss-rate and, consequently, a progressive arthrosis/necrosis/persistent nonunion of 8.8%. The patients who had vital reconstructed carpal bones did not report pain, but motion and grip strength were decreased as compared with the uninvolved side. This procedure offers stability and vascularity to treat avascular scaphoid nonunion and has proved beneficial in achieving union in avascular scaphoid pseudoarthrosis and lunate necrosis. It can be considered to be the definitive alternative technique. The high rate of union and the absence of progressive carpal arthrosis are the best evidence for the vascularity of the bone graft.