Mark R. Belsky

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.

Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome

Partial resection of the distal ulna (wafer resection) has been used to treat patients with symptomatic tears of the triangular fibrocartilage complex or mild ulna impaction syndrome. In this procedure, the distal 2 to 4 mm of the distal ulnar head is resected while preserving the ulnar styloid process and the ligaments attached to it. The triangular fibrocartilage is debrided, repaired, or partially excised as necessary. The procedure is contraindicated if there is more than 4 mm of positive ulnar variance. Thirteen wafer resections of the distal ulna were performed in 12 patients. All had good to excellent results after a minimum follow-up of 1 year. Wafer resection has specific advantages and avoids many of the potential complications of distal ulna recession and ulnar head resection for patients with the conditions described. The procedure is not indicated if instability or degenerative arthritis of the distal radioulnar joint is present or if there is carpal instability.

Closed reduction and internal fixation of proximal phalangeal fractures.

Displaced fractures of the shaft of the proximal phalanx can lead to marked deformity and disability when poor results are obtained. Despite the attention popular concepts of open reduction and internal fixation have received, a less invasive technique has been our standard approach. A prospective study of closed reduction and percutaneous Kirschner wire fixation in 100 consecutive fractures yielded good or excellent results in 90% of cases when treated within 5 days of injury.

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.

Injury to the Deep Motor Branch of the Ulnar Nerve During Carpal Tunnel Release

Complications following carpal tunnel release have been reported to occur in 12-20%’ of cases and are numerous and varied. Neurologic complications that have been reported usually involve the palmar cutaneous or motor branch of the median nerve.’ Ulnar nerve injury during carpal tunnel release has been reported rarely. The only cases reported include cases of injury to the main ulnar palmar cutaneous nerve,* the ramus communicans3 (a normal sensory communication between the ulnar and median nerve in the palm), and a partial ulnar nerve injury in Guyon’s cana1.4 We have encountered three cases of injury to the deep motor branch of the ulnar nerve just distal to the hook of the hamate in the midpalmar space. All injuries occurred during routine carpal tunnel release performed by experienced orthopaedic surgeons and were not appreciated intraoperatively. Case Reports

Hand involvement in psoriatic arthritis

From a population of 105 patients with confirmed psoriatic arthritis, 25 patients required hand surgery. These 25 surgical patients were evaluated retrospectively both clinically and radiographically. The patterns of hand and wrist involvement as well as the results of surgery differed from those typically seen in rheumatoid disease. Spontaneous fusion of the wrist in a functional position, severe proximal interphalangeal involvement often with marked flexion contractures, severe erosion of the distal interphalangeal joint with spontaneous fusions, and generalized stiffness characterize these hands. Minimal improvement in motion and a significantly increased incidence of infection following arthroplasty were noted.

Distal biceps tendon tears in women.

HYPOTHESIS Is the presentation and outcome of surgical treatment of distal biceps tendon tears different in women than men? MATERIALS AND METHODS From 1999 to 2008, 15 cases of distal biceps tendon tears in 13 female patients were treated surgically at a single institution. Mean age was 63 years (range, 48-79 years). A retrospective review evaluated patient presentation, diagnosis, and treatment. Postoperative outcomes were assessed by physical examination, a patient satisfaction survey, the American Shoulder and Elbow Surgeons (ASES) elbow assessment form, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS Two-thirds of the tears were in the dominant arm, of which 7 resulted from a single injury, and 8 reported insidious onset of symptoms. All patients presented with pain in the antecubital fossa. A distinct cystic mass was palpable in 6. Of the 15 cases, 13 were partially detached, 1 was completely detached, and 1 was weakly attached. Fourteen regained full strength, and all had nearly complete range of motion. Mean follow-up was 46 months (range, 2-117 months). Eleven completed a postoperative patient satisfaction survey, ASES elbow, and DASH questionnaire. Mean scores were 95 (range, 58-100) for ASES and 7 (range, 0-43) for DASH. The only complication was a transient lateral antebrachial cutaneous nerve sensory palsy. DISCUSSION Distal biceps tendon tears in women present at an advanced age with no history of an acute injury. They are frequently associated with a cystic mass and have a predominance of partial tears. CONCLUSIONS Distal biceps tendon tears in women present differently than in men. The tears are rarely complete and they respond well to surgical repair.

Pisiform-hamate coalition with ulnar neuropathy

Two cases of pisiform-hamate coalition with compression of the ulnar nerve at the wrist are reported. Pisiform-hamate coalition is a rare entity previously thought to be exclusive to West Africans and without clinical significance. These cases occurred in white patients. This is the first description of a carpal coalition resulting in ulnar neuropathy at the wrist.

Quantitative 3-Dimensional CT Analyses of Intramedullary Headless Screw Fixation for Metacarpal Neck Fractures

PURPOSE Fixation countersunk beneath the articular surface is well accepted for periarticular fractures. Limited open intramedullary headless compression screw (HCS) fixation offers clinical advantages over Kirschner wire and open techniques. We used quantitative 3-dimensional computed tomography to assess the articular starting point, surface area, and subchondral volumes used during HCS fixation of metacarpal neck fractures. METHODS We simulated retrograde intramedullary insertion of 2.4- and 3.0-mm HCS and 1.1-mm Kirschner wires for metacarpal neck fracture fixation in 3-dimensional models from 16 adults. We used metacarpal head articular surface area (mm(2)) and subchondral volumes (mm(3)) and coronal and sagittal plane arcs of motion, during which we analyzed the center and rim of the articular base of the proximal phalanx engaging the countersunk entry site. RESULTS Mean metacarpal head surface area mated to the proximal phalangeal base in neutral position was 93 mm(2); through the coronal plane arc (45°) was 129 mm(2), and through the sagittal plane arc (120°) was 265 mm(2). The mean articular surface area used by countersunk HCS threads was 12%, 8%, and 4%, respectively, in each of these arcs. The 1.1-mm Kirschner wire occupied 1.2%, 0.9%, and 0.4%, respectively. Mean metacarpal head volume was 927 mm(3). Mean subchondral volume occupied by the countersunk portion was 4%. The phalangeal base did not overlap the dorsally located countersunk entry site through most of the sagittal plane arc. During coronal plane motion in neutral extension, the center of the base never engaged the dorsally located countersunk entry site. CONCLUSIONS Metacarpal head surface area and subchondral head volume occupied by HCS were minimal. Articular surface area violation was least during the more clinically relevant sagittal plane arc of motion. CLINICAL RELEVANCE The dorsal articular starting point was in line with the medullary canal and avoided engaging the center of the articular base through most of the sagittal plane arc. Three-dimensional computed tomography data support the use of an articular starting point for these extra-articular fractures.

Scaphoid Fracture in the Elite Athlete

Scaphoid fracture remains a common, potentially devastating, injury that can impair upper extremity function. Early recognition with proper imaging and treatment provides the best opportunity to heal and return to a normal activity level. Surgical treatment offers the patient a quicker return to the rehabilitation of the extremity and therefore an earlier return to elite play. There is evidence that healing occurs faster if the fractured scaphoid is fixed with internal fixation. Absolute compliance by the athlete and the training program that surrounds the athlete is critical to protect the wrist while maintaining the necessary conditioning of an elite athlete.