Paul Feldon

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.

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.

Intrinsic Muscle Flaps: The Treatment of Painful Neuromas in Continuity

Treatment of the pain that is caused by neuroma in continuity in a digital nerve on the palmar surface of the hand is a challenging problem. Eight digital nerves were covered with intrinsic muscle flaps after neurolysis to obtain relief of symptoms in eight patients. Four of the cases involved intrinsic muscles for digital nerves in the thumb. Four patients had digital nerves in the palm covered by lumbrical muscle flaps, two of which were distally based. All patients had significant relief of their symptoms. This report describes the techniques used and their application.

Evaluation and Treatment of the Rheumatoid Wrist

Operative treatment of the rheumatoid wrist ineludes both preventive and reconstructive procedures. It is undertaken only after the problems. deformity. and needs of the individual patient have been carefully evaluated. In some patients. preventive procedures, such as a synovectomy of the nadiocanpal joint or the distal radio-ulnar joint. or both. is appropriate. In others, a reconstructive procedure. such as a tendon transfer, a reconstruction of the distal radio-ulnan joint. a partial or total arthrodesis of the wrist, on a wrist arthnoplasty, is indicated. Some patients need a combination of procedunes from both categonies”23554’ ’.

Carpal Tunnel Syndrome in Rheumatoid Arthritis

Summary: Carpal tunnel (CTS) syndrome is the most common compression neuropathy associated with rheumatoid arthritis (RA). Pain and/or paresthesias at night as well as weakness, loss of dexterity, and thenar atrophy can occur. CTS in RA patients is not always obvious, as these symptoms are common complaints in the RA population. Therefore, every patient with RA should be evaluated for CTS. Flexor tenosynovitis (FTS) is the common denominator in patients with CTS and RA. FTS must be treated concomitantly with CTS, and the surgeon should be prepared for the possibility of tendon ruptures and/or exposed bone spurs in the carpal canal. Severe RA wrist destruction with volar subluxation or dislocation of the carpus can result in median nerve compression with CTS symptoms. Median nerve compression also can occur after wrist arthrodesis in RA patients.