Michael E. Rettig

WRIST FRACTURES IN THE ATHLETE: Distal Radius and Carpal Fractures

The primary prerequisites for optimal management of the athletes fractured wrist are prompt diagnosis, anatomic and stable reduction, effective immobilization until healing is thorough, and comprehensive rehabilitation of the injured parts. Fulfillment of these fundamental criteria consistently leads to a highly favorable outcome with minimal risk of re-injury. In contrast, a compromise of these principles, especially for the sake of a speedy return to sports, invariably results in suboptimal recovery and, not infrequently, a permanent loss of skills. The exceptions to the cardinal rule that successful treatment of wrist fractures requires precise restoration of anatomic relationships are specific: displaced hamate hook fractures, displaced trapezial ridge fractures, and comminuted pisiform fractures. In such instances, successful union essentially is precluded, and early excision of the displaced fragments is the logical means of facilitating an uncomplicated recovery. For the more complex fractures requiring stabilization, continual refinements in methods of fixation are considerably diminishing fracture morbidity. The availability of small screws that provide rigid fixation of the carpus is, with increasing consistency, promoting accelerated union and rapid rehabilitation. Well-conceived combinations of low-profile, mechanically efficient external fixators and precisely used Kirschner wires achieve highly secure fracture stability for the distal radius that similarly enhances recovery with a minimum of complications. Improvements in both design and application of internal and external fixation techniques undoubtedly constitute a major advance in the management of wrist fractures among athletes. For some athletes, the return to competition can be safely expedited by the use of custom-fit protective gloves, splints, or casts. For most, however, the treatment regimen usually entails a minimum of 3 to 4 months. Although the healing and rehabilitation process is often lengthy and may seem costly, particularly in terms of time lost from competition, seldom do athletes regret the investment once they return to their highly skillful activities unencumbered by wrist impairment. Never does the sports medicine physician regret compliance with the principles of optimal care.

Avulsion injuries of the flexor digitorum profundus tendon.

Abstract Avulsions of the flexor digitorum profundus tendon may involve tendon retraction into the palm and fractures of the distal phalanx. Although various repair techniques have been described, none has emerged as superior to others. Review of the literature does provide evidence‐based premises for treatment: multi‐strand repairs perform better, gapping may be seen with pullout suture‐dorsal button repairs, and failure because of bone pullout remains a concern with suture anchor methods. Clinical prognostic factors include the extent of proximal tendon retraction, chronicity of the avulsion, and the presence and size of associated osseous fragments. Patients must be counseled appropriately regarding anticipated outcomes, the importance of postoperative rehabilitation, and potential complications. Treatment alternatives for the chronic avulsion injury remain patient‐specific and include nonsurgical management, distal interphalangeal joint arthrodesis, and staged reconstruction.

Acute Scapholunate Ligament Instability

THE PATIENT A 31-year-old right-hand-dominant male professional dancer felt pain during hyperextension of his right wrist attempting to pick up his dance partner 2 weeks before presentation. He presents with pain and weakness in the right wrist. There is obvious swelling and tenderness dorsally at the scapholunate (SL) interval of the right wrist. His grip strength is measured 20% of the uninvolved side using a hand dynamometer. The scaphoid shift test was too painful to perform. A posteroanterior static wrist radiograph demonstrates an SL interval of 4 mm and a cortical ring sign. The lateral wrist radiograph reveals a radiolunate angle of 30 and an SL angle of 95 .

Management of Pisotriquetral Instability

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

Brachial Plexus Blockade Causes Subclinical Neuropathy A Prospective Observational Study

Background: The objective of this study is to determine subclinical changes in hand sensation after brachial plexus blocks used for hand surgery procedures. We used Semmes-Weinstein monofilament testing to detect these changes. We hypothesized that patients undergoing brachial plexus nerve blocks would have postoperative subclinical neuropathy detected by monofilament testing when compared with controls. Methods: In total, 115 hand surgery adult patients were prospectively enrolled in this study. All patients undergoing nerve-related procedures were excluded as well as any patients with preoperative clinically apparent nerve deficits. Eighty-four patients underwent brachial plexus blockade preoperatively, and 31 patients underwent general anesthesia (GA). Semmes-Weinstein monofilament testing of the hand was performed preoperatively on both the operative and nonoperative extremities and postoperatively at a mean of 11 days on both hands. Preoperative and postoperative monofilament testing scores were compared between the block hand and the nonoperated hand of the same patient, as well as between the block hands and the GA-operated hands. Results: There were no recorded clinically relevant neurologic complications in the block group or GA group. A statistically significant decrease in sensation in postoperative testing in the operated block hand compared with the nonoperated hand was noted. When comparing the operated block hand with the operated GA hand, there was a decrease in postoperative sensation in the operated block hand that did not reach statistical significance. Conclusions: Brachial plexus blockade causes subtle subclinical decreases in sensibility at short-term follow-up, without any clinically relevant manifestations.

An Atlas of Surgical Techniques of the Hand and Wrist

An Atlas of Surgical Techniques of the Hand and Wrist. Raoul Tubiana, Alain Gilbert, and Alain C. Masquelet. With illustrations by Leon Dorn. Philadelphia, Lippincott Williams and Wilkins, and London, Martin Dunitz, 1999.

Galeazzi fracture-dislocation: A new treatment-oriented classification ☆ ☆☆

235.00, 517 pp. All of the procedures in this book are described by three prominent hand surgeons who have a wealth of expertise in the field. There are ten sections, each of which is …