William H. Bowers

Distal radioulnar joint arthroplasty: The hemiresection-interposition technique

The hemiresection-interposition technique for distal radioulnar joint arthroplasty was developed from anatomic studies that indicated the importance of preserving the functional elements of the ulnocarpal ligament complex. The technique has been previously described. My experience with 38 patients who were followed for an average of 2 1/2 years shows that the procedure is most valuable for patients with rheumatoid arthritis (85% had stable, painless pronation averaging 84 degrees and supination of 77 degrees, while 15% had mild pain and pronation of 70 degrees and supination of 75 degrees). It is also valuable for patients with degenerative or trauma-induced arthritis (100% had painless rotation-pronation averaging 80 degrees and supination of 80 degrees). A modified procedure is useful for patients with ulnocarpal impingement syndrome where the Milch shortening osteotomy may not succeed because of radioulnar incongruity.

Ulnar variance—The effect of wrist positioning and roentgen filming technique

Ulnar variance--the roentgenographic distance between contiguous articular surfaces of the distal radiocarpal and ulnocarpal joints--changes with wrist and forearm position. Supination increases the measurement of negative ulnar variance. Pronation decreases the measurement of negative ulnar variance. Wrist deviation and alterations of the x-ray beam in the longitudinal plane also influence the measurement. A standardized wrist roentgenogram has been developed to allow accurate and reproducible measurements of ulnar variance. Internal landmarks for recognizing the standard views are introduced. The use of standard wrist roentgenographic techniques for all wrist films is recommended.

The proximal interphalangeal joint volar plate. I. An anatomical and biomechanical study

The anatomy and biomechanics of the volar plate are reviewed. From a study of 60 fresh adult specimens, the authors present a consolidated anatomic concept of this structure, emphasizing the distinctiveness of the proximal attachments, the variable nature of the distal attachments, and the complex relationships to the flexor sheaths, the vincula, and the collateral ligaments. Experimental biomechanical data suggest that the nature and site of injury to this structure is dependent on the rate of application of force: rapid rates produce rupture at the distal attachment, slow rates attenuate the proximal check ligaments.

Closed traumatic rupture of finger flexor pulleys

Nine patients are described with closed traumatic rupture of the digital flexor pulley system. All presented with significant flexion contractures of the proximal interphalangeal joint and bow-stringing of the flexor tendons. In seven patients, the pathology was verified at surgery and pulley reconstruction provided a good result. The diagnoses in the other patients, treated conservatively, were verified by tenogram and magnetic resonance imaging.

The proximal interphalangeal joint volar plate. II: A clinical study of hyperextension injury

The surgical anatomy and clinical course of the pure hyperextension injury of the proximal interphalangeal (PIP) joint is described based on observations in 12 patients coupled with 15 cases from the literature and vascular injection study of the volar plate. The conclusions are (1) virtually all pure hyperextension injuries produce a rupture of the volar plate at the distal end and (2) such a rupture, when not associated with a marginal metaphyseal avulsion fracture, is not easily diagnosed and is likely to eventuate in a chronic posttraumatic hyperextension deformity because relatively avascular injured tissue is insufficiently immobilized.

Ulnar head implant arthroplasty: an intermediate term review of 1 surgeon's experience.

Ulnar head arthroplasty has been an emerging alternative for salvage of resection arthroplasty at the distal radioulnar joint (DRUJ) since the early 1990s. Recently, it has been offered for initially treating painful arthrosis or instability of the DRUJ. This follow-up study reports a surgeons experience treating DRUJ disorders with ulnar head arthroplasty. Twenty-two wrists in 20 patients (11 females, 9 males), 6 with no prior wrist procedures were treated between 1995 and 2006 for painful DRUJ disorders with either Herbert-Martin (Martin Medizin-Technik, Tuttingen, Germany) or Avanta (Small Bone Innovations, New York, NY) head prosthesis. Follow-up averaged 54.3 months. A standardized telephone survey determined preoperative /postoperative verbal analog pain scores and a modified Mayo Wrist Score (delineating poor, fair, good, or excellent outcomes). Data suggest that ulnar head implant arthroplasty is a reasonable treatment option for DRUJ-related pain, loss of function, or salvage of failed distal ulna resection procedures. The analog pain score statistically significant decreased by 1.68 points when comparing preoperative to postoperative scores. Average Modified Mayo Wrist Scores were good, independent of whether the procedure was primary or salvaged. No significant difference was seen between the primary or salvage group modified Mayo Wrist Scores. Whereas averaged modified Mayo scores for both the primary and salvage groups were in the good category, prostheses used as primary procedures may be associated with fewer poor or fair outcomes. Two good and 1 excellent outcome of 3 wrists requiring revision procedures suggest that even with revision of the implant arthroplasty, satisfactory results may be expected.

Range of Motion Effects of Distal Pole Scaphoid Excision and Triquetral Excision After Radioscapholunate Fusion: A Cadaver Study

PURPOSE Radioscapholunate (RSL) fusion is an effective surgical procedure for the treatment of isolated radiocarpal arthritis. Although functional wrist motion is typically preserved through the midcarpal joint, many patients are still frustrated by postoperative limitations. The purpose of this study was to evaluate motion of cadaver wrists after simulated RSL fusion with excision of the distal pole of the scaphoid and the triquetrum. METHODS Ten fresh-frozen cadaver upper extremities were mounted on a custom testing apparatus after isolation of the flexor carpi radialis, flexor carpi ulnaris, extensor carpi radialis longus, and extensor carpi ulnaris tendons. Sequential loading of these tendons resulted in flexion, extension, radial, and ulnar deviation. We subsequently measured range of motion with the use of digital photography. All specimens were tested in 4 states: intact (normal), RSL fusion (simulated), RSL fusion with distal scaphoid pole excision, and RSL fusion with distal scaphoid pole and triquetrum excision. The results were statistically analyzed using a repeated measures analysis of variance. RESULTS Range of motion decreased to 39% to 46% of normal for flexion and extension and 65% to 71% of normal for radial and ulnar deviation after simulated RSL fusion. The addition of distal pole of scaphoid excision resulted in flexion and extension returning to 72% to 79% of normal, and radial and ulnar deviation returning to 84% to 89% of normal. Excision of the triquetrum further increased flexion and extension to 87% to 97% of normal, and radial and ulnar deviation to 119% to 137% of normal. CONCLUSIONS The combination of triquetral and distal scaphoid pole excision after RSL fusion improves wrist motion to levels close to normal in the cadaver model.

Congenital deficiency of the ulna

Twenty-three patients with ulnar ray deficiency were studied and the deformities described by combining Kummels and Swansons classifications. An individualized, functionally oriented management program is recommended with early resection of the fibrocartilaginous remnant to prevent shortening, radial bowing, and possible malrotation. Rotational deformity can be corrected by wedge osteotomy, rotation osteotomy, or proximal radial ulnar synostosis. Improved motion at the elbow can be obtained by release of contractures or resection of the radial head. Wrist deformity may require resection of the ulnar remnant and a wedge osteotomy of the radius.

Congenital absence of the triquetrum: A case report

A case of congenital absence of the triquetrum in a 47-year-old man is reported. The etiology could be related to deficient chondrification or ossification. Conservative treatment relieved his symptoms of pain and weak grasp.

Scaphoid impression fracture: A case report

A unique fracture of the distal radial articular surface is reported. The fracture appears to be the result of an impaction of the scaphoid on the radius.