Ronit Wollstein

Scaphoid and lunate translation in the intact wrist and following ligament resection: A cadaver study

PURPOSEnTo determine the amount of scaphoid and lunate translation that occurs in normal cadaver wrists during wrist motion, and to quantify the change in ulnar translation when specific dorsal and volar wrist ligaments were sectioned.nnnMETHODSnWe measured the scaphoid and lunate motion of 37 cadaver wrists during wrist radioulnar deviation and flexion-extension motions using a wrist joint motion simulator. We quantified the location of the centroids of the bones during each motion in the intact wrists and after sectioning either 2 dorsal ligaments along with the scapholunate interosseous ligament or 2 volar ligaments and the scapholunate interosseous ligament.nnnRESULTSnIn the intact wrist, the scaphoid and lunate statistically translated radially with wrist ulnar deviation. With wrist flexion, the scaphoid moved volarly and the lunate dorsally. After sectioning either the dorsal or volar ligaments, the scaphoid moved radially. After sectioning the dorsal or volar ligaments, the lunate statistically moved ulnarly and volarly.nnnCONCLUSIONSnMeasurable changes in the scaphoid and lunate translation occur with wrist motion and change with ligament sectioning. However, for the ligaments that were sectioned, these changes are small and an attempt to clinically measure these translations of the scaphoid and lunate radiographically may be limited. The results support the conclusion that ulnar translocation does not occur unless multiple ligaments are sectioned. Injury of more than the scapholunate interosseous ligament along with either the dorsal intercarpal and dorsal radiocarpal or the radioscaphocapitate and scaphotrapezial ligaments is needed to have large amounts of volar and ulnar translation.

Long-term complications of distal radius bone grafts.

PURPOSEnTo assess long-term results and complications of cancellous bone graft taken from the distal radius.nnnMETHODSnA total of 1670 cases of bone graft taken from the distal radius for various indications were reviewed retrospectively. The patients were evaluated for success of bone grafting and for the following complications: fracture through donor site, local infection, DeQuervains tenosynovitis, and neuroma of the superficial radial nerve.nnnRESULTSnThe overall complication rate including bone graft failure within a mean follow-up period of 4.5 years was 4%. Bone graft failure required regrafting with iliac bone in 38 patients (2.3%). DeQuervains tenosynovitis was noted in 21 patients (1.3%), local soft-tissue infection was noted in 3 patients (0.2)%, fracture through donor site was noted in 2 patients (0.1%), and superficial radial nerve neuromas were noted in 2 patients (0.1%). There were no cases of osteomyelitis.nnnCONCLUSIONSnBone grafting from the distal radius is effective with minimal complications and is a practical adjunct to reconstructive hand procedures.

A tailored approach to the surgical treatment of cubital tunnel syndrome.

Multiple studies have compared the outcome of surgery for cubital tunnel syndrome (CUTS), yet there remains no clear guidelines for treatment. We describe an approach to CUTS that includes tailoring the procedure to the pathology found at surgery. Patients treated surgically were retrospectively reviewed. Following in situ neurolysis, nerve stability within the cubital tunnel was assessed, and the nerve was left in situ, or transposed accordingly. We evaluated demographic information, presenting features, intraoperative and postoperative findings. Statistics included paired t test and logistic regression analysis. A total of 63 patients (standard deviation = 10.3 years) were reviewed. Fourteen nerves were transposed (22.5%). Postoperatively, sensation (71%), static 2-point discrimination, and motor strength improved. Grip strength compared with the uninvolved side was 94.8% postoperatively. Overall, 90% of the patients reported improvement in function. Our results compare favorably with other studies. Since CUTS originates from numerous causes, basing the operative plan on intraoperative findings produces excellent results.

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.

The Importance of Early Operative Treatment in Open Fractures of the Fingers

IntroductionCurrent guidelines suggest early surgical treatment of open fractures. This rule in open hand fractures is not well supported and may be practically difficult to observe. Furthermore, desirable washout can be obtained in the emergency department (ED). The purpose of this study was to determine the importance of early surgery in our institution. MethodsSeventy patients with open fractures of the hand were retrospectively reviewed for demographics, fracture characteristics, and complications. Statistical analysis included univariate analysis, Fisher exact test, and Akaike information criterion. ResultsIntravenous antibiotics were administered early in 53 (75.7%) patients. Mean (SD) time to surgery was 2.3 (134.9) hours. The infection rate was 11.4%. No significant relationship was found between fracture type, finger involved, hand dominance, comorbidities, and infection. Antibiotic administration was significantly related to infection (P = 0.007), whereas time to surgery was not (P = 0.33). Age was weakly related to infection (P = 0.08). DiscussionAdministration of intravenous antibiotics in the ED was the most significant factor in preventing infection, whereas the time to operation was not significant. Because a thorough washout and debridement can be performed on open hand fractures in the ED due to the ability to provide adequate anesthesia, the actual time to surgery may possibly be delayed without increasing the risk of infection. Future prospective studies may allow for better guidelines for the treatment of open hand fractures.

Osteoarthritis of the Wrist STT Joint and Radiocarpal Joint

Our understanding of wrist osteoarthritis (OA) lags behind that of other joints, possibly due to the complexity of wrist biomechanics and the importance of ligamentous forces in the function of the wrist. Scaphotrapeziotrapezoidal (STT) OA is common, but its role in wrist clinical pathology and biomechanics is unclear. We identified the prevalence of radiographic STT joint OA in our hand clinic population and defined the relationship between STT and radiocarpal OA in wrist radiographs. One hundred consecutive wrist clinical and radiographic exams were retrospectively reviewed. Radiographs were evaluated for the presence and stage of OA. The mean age was 61.3 (±14.5) years. The radiographic occurrence of STT joint OA was 59% and of radiocarpal (RC) OA was 29%. Radiographic STT and RC joint OA were inversely related. Tenderness over the STT joint in physical exam was not associated with OA in the STT or other joints. STT OA in our series was not related to wrist pain. These findings support the discrepancy between radiographic and cadaver findings and clinically significant OA in this joint. The inverse relationship between STT and RC OA, as seen in scapholunate advanced collapse (SLAC) wrist, requires further biomechanical study.

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.

Mycobacterium monacense: A Mycobacterial Pathogen That Causes Infection of the Hand

We present a report of a diabetic patient with an infection of his left thumb and thenar eminence. Standard cultures of drainage and tissue biopsy were unrevealing. The infection progressed despite empiric antibacterial agent therapy and multiple debridements. Two intraoperative tissue biopsies revealed a yellow-pigmented, rapidly growing Mycobacterial nontuberculous species. The organism was identified as Mycobacterium monacense, a newly described species. The patient was cured with a 6-week course of clarithromycin and levofloxacin.

SCAPHOID TRANSLATION MEASUREMENTS IN NORMAL WRISTS

The purpose of this study was to establish a normal measure of scaphoid position in the radioulnar plane in standard neutral, radial and ulnar deviation posteroanterior radiographs. This measurement may allow indirect evaluation of the radiocarpal ligaments and comparison between normal and pathologic states (following radius fractures, perilunate dislocations). Measurements were trialed on 74 normal wrist radiographs and 25 cadaver wrists. We evaluated the distance between the radial styloid and the scaphoid and corresponding scaphoid width. The ratio of distance/width at the mid styloid level (0.35, imprecision SD = 0.1) had the lowest random error and is therefore the most precise measurement of true scaphoid translation. This measurement is independent of scapholunate ligament integrity and may provide a better assessment of the radiocarpal component of ulnar translational instability. Abnormal movement of the scaphoid in the radioscaphoid joint likely reflects ligamentous injury. Identifying and addressing these injuries may prevent the development of arthritis.