Thomas J. Graham

The distal radioulnar joint capsule: Clinical anatomy and role in posttraumatic limitation of forearm rotation*

Posttraumatic limitation of forearm rotation can be the result of pathology at any location along the forearm axis. Scar contracture of the distal radioulnar joint (DRUJ) capsule, independent of the triangular fibrocartilage complex (TFCC), is one of the sources that may influence the pronosupination arc. We dissected the wrists of 8 fresh-frozen cadaver specimens to characterize the precise anatomy, relationships, and dynamic characteristics of the entire DRUJ capsule. Additionally, we performed surgical DRUJ capsulectomy in 9 patients with recalcitrant limited forearm pronosupination that was unattributable to dysfunction at any other anatomic forearm location. We conclude that (1) the DRUJ capsule is a defined entity, separate from the triangular fibrocartilage, that is highly specialized to accommodate the distal ulna in forearm rotation; (2) in patients who have restored osseous anatomy after trauma, but have failed to regain pronosupination after maximal rehabilitation, the DRUJ capsule can be identified as the source of the limitation; and (3) DRUJ capsulectomy can markedly improve the arc of forearm rotation in carefully selected patients.

Classification and treatment of postburn proximal interphalangeal joint flexion contractures in children.

Two hundred and sixty-four surgically treated proximal interphalangeal joint flexion contractures in children were reviewed. A classification system on the basis of contracture severity was devised to assess the efficacy of treatment. Contracture severity was determined from preoperative radiographs and physical examination. Eighty-eight percent of the digits were successfully treated (postoperative contracture less than 20 degrees). Unsatisfactory results (12% of digits) were directly proportional to the severity of the contracture and tended to occur in older children with large total body surface burns. The time interval between burn and contracture release did not correlate with contracture severity or therapeutic failure. The most common cause of an unsatisfactory result was failure to fully release the contracture.

A comprehensive approach to surgical mangement of the type IIIA hypoplastic thumb

In order to adequately identify pathologic anatomy and effectively reconstruct 14 type IIIA hypoplastic thumbs, a comprehensive clinical evaluation and surgical approach was employed. Eleven patients had congenital differences in the forearm, while all patients had anomalies in the wrist, hand, and digits. In addition to well-described interconnections between the flexor pollicis longus and the extensor pollicis longus, and thenar muscle hypoplasia, the authors observed duplication of musculotendinous units, anomalous muscles between the thumb and index rays, and abnormal insertions or dense adhesions along tendons as proximal as the forearm level. Successful reconstruction required an extended approach from the digit to the forearm, through which division of abnormal connections, reorientation of tendons, and lysis of adhesions was performed. Opposition transfer was needed in only 8 of the patients after the other pathologies were treated. Web-space deepening and ulnar collateral ligament reconstruction was performed when indicated. Improvement in function and appearance was achieved.

Classification and treatment of postburn metacarpophalangeal joint extension contractures in children

Two hundred and seventy-eight surgically treated postburn metacarpophalangeal joint extension contractures in children were reviewed. A classification system based on the limitation of passive metacarpophalangeal flexion was devised to direct surgical intervention and assess postoperative results. Type I (47%) digits demonstrated greater than 30 degrees of metacarpophalangeal flexion with the wrist fully extended, and scarring was generally limited to the dorsal skin. Type II (34%) digits demonstrated less than 30 degrees of metacarpophalangeal flexion with the wrist maximally extended, and scarring typically involved skin, dorsal apparatus, and metacarpophalangeal capsule. Type III (19%) digits were fixed in greater than 30 degrees of metacarpophalangeal hyperextension and often demonstrated incongruity or dorsal subluxation of the metacarpophalangeal joint. Improvement after reconstruction was seen in 95% of type I digits, 73% of type II digits, and 47% of type III digits. Failure to improve usually resulted from inadequate scar release/excision or from failure to release deep soft tissues (dorsal apparatus or metacarpophalangeal capsule). Thirty secondary procedures were done to improve an unsatisfactory result after the initial reconstruction. These included deep releases, metacarpophalangeal joint arthrodeses, and amputations. The ring and small fingers accounted for 65% of the digits in this study, 68% of the failures, and all seven amputations.

Pathologies of the Extensor Carpi Ulnaris (ECU) Tendon and its Investments in the Athlete

Those who have dedicated significant time to the study and care of stick-and-ball athletes have an appreciation for the unique anatomy, unusual forces, and proclivity for injury. It is imperative that hand surgeons involved in the care of baseball, hockey, tennis, and golf athletes appreciate the anatomic and mechanical elements of extensor carpi ulnaris (ECU) pathology. It is necessary to maintain a high level of suspicion for ECU problems, among other ulnar wrist pathologies, as well as acute diagnostic skill and a portfolio of therapeutic alternatives for their treatment.

A Radiocarpal Ligament Reconstruction Using Brachioradialis for Secondary Ulnar Translation of the Carpus Following Radiocarpal Dislocation: A Cadaver Study

PURPOSE Radiocarpal dislocation damages the radiocarpal ligaments, typically eliminating the possibility for repair. The goals of this study were to create a model for ulnar translation of the carpus and design a soft-tissue reconstruction using the brachioradialis (BR) to prevent ulnar translation of the carpus. We primarily sought to recreate the stabilizing effect of the radioscaphocapitate ligament. METHODS Eight cadaveric upper limbs were dissected, leaving only the BR tendon. The wrist was loaded perpendicular to the long axis of the forearm, and load-displacement curves for ulnar translation were generated. The radiocarpal ligaments were sectioned. Substantial ulnar translation was seen only after complete release of the palmar and dorsal radiocarpal ligaments. Reconstruction was performed with the BR tendon, maintaining the insertion on the radial styloid. The proximal tendon stump was brought distally through a drill hole in the center of the capitate, palmar to dorsal, and secured to the dorsal rim of the radius with a suture anchor. The specimens were then retested after this reconstruction. Qualitative evaluation of graphs plotted, mini c-arm fluoroscopy, and visual observation was also performed. RESULTS Comparison of the intact specimens and the specimens after sectioning of the radiocarpal ligaments revealed a significant difference between mean ulnar translation (11.1 mm vs 18.4 mm; p < 0.05). Comparison of the sectioned specimens before and after BR reconstruction demonstrated a statistically significant difference in mean ulnar translation (18.4 mm vs 10.6 mm; p < 0.05). Comparison of the intact specimens and the specimens after sectioning-reconstruction did not demonstrate a significant difference, indicating that the BR reconstruction re-established the stability seen in the intact specimens with regard to ulnar translation (11.1 mm vs 10.6 mm; p > 0.05). CONCLUSIONS The model consistently produced significant ulnar translation after division of the radiocarpal ligaments. The BR reconstruction was primarily designed to restore the function of the radioscaphocapitate ligament. This biomechanical study demonstrates the ability of this reconstruction to generate a statistically significant restraint to ulnar translation in a cadaver model of radiocarpal dislocation.

Adductor pollicis jamming injuries in the professional baseball player: 2 case reports.

We characterize a mechanism of injury, injury pattern, and treatment algorithm for adductor pollicis myotendinous injuries in 2 professional baseball players. Similar to myotendinous eccentric injuries in other anatomical areas, the adductor pollicis sustains a sudden forceful eccentric load during a jammed swing, resulting in intramuscular strain or tendon rupture. Based on the reported injury mechanism, and magnetic resonance imaging features of these myotendinous injuries, the thumb of the top hand during a jammed swing was suddenly and forcefully eccentrically abducted from a contracted and adducted position, resulting in injury patterns.

Perspective on Scapholunate Ligament Injuries in Baseball Players

cl in ic s. co m I believe one of the most challenging injuries we deal with in professional sports is the spectrum of scapholunate (SL) ligament pathologies. These conditions present diagnostic and therapeutic challenges, and they are difficult to define and explain (to the front office, trainers, and players). Also, there is ambiguity about return to play in both the surgically and nonsurgically treated patient/player. Nocontact sport athlete is immune fromthepossibility of SL ligament injury. In my experience, these injuries have resulted from collisions with opponents or the wall when making/attempting a catch. Whether we can actually ascribe a primary injury to a swing of the bat is a little more obscure, that is, did the torqueplacedon thewrist by the high angular velocity action with a long lever arm create the pathology or just exacerbate an existing tear. The one benefit I have realized in over 2 decades of care of the elite athlete is that fewer diagnostic delays occur at the professional level. The excellent trainers and readily available access to studies such as magnetic resonance imaging (MRI) likely alert us to even partial tears that may go undiscovered in other venues. I have long maintained a relatively low threshold for ordering an MRI (noncontrast)—I don’t want to be remembered as the hand surgeon who missed the SL ligament tear (or Kienbock disease and so forth). Therefore, spending a great deal of time on physical examination or imaging concepts in a commentary like this is not indicated. I’d prefer to discuss the management of partial and complete SL tears and its implications on a baseball