Factors prolonging disability in work-related cumulative trauma disorders.

Workers' compensation costs for management of soft tissue disorders continue to increase. The complexity of medical management of these cases has increased due to social factors. The purpose of this study is to improve the physician's ability to recognize nonmedical issues that prevent a rapid return to employment. A classification system is presented that will allow the clinician to identify administrative and pyschosocial issues that prolong disability. Additionally, the patients' job demands were classified by known ergonomic risk factors. The system was applied retrospectively to 50 random cases referred to two occupational hand clinics over a 1-year period. The results indicated that the psychosocial classification of the patient and the current employment status are the most important factors in prolonging disability workers.

A team approach to reduce disability in work-related disorders.

Work-related disorders require a multidisciplinary approach. One must understand musculoskeletal disorders, job issues, and psychosocial issues that prolong disability. This introductory article presents an overview of the approaches to management that will be detailed in the articles that follow.

Occupational soft-tissue and tendon disorders.

Reports of work-related musculoskeletal disorders have increased. The cause of the problem has yet to be determined. Thus far, only cross-sectional case and controlled studies exist. It is important for the physician to develop a thought process to separate patients with subjective complaints and real objective findings from those with unreasonable subjective complaints and minimal or no findings.

Management of work-related upper-extremity nerve entrapments.

Peripheral nerve symptoms are common in the worker. Great care must be given to obtain an accurate diagnosis. Diagnostic labels should not be used unless one is sure of the diagnosis. A detailed evaluation of the worker, job, and medical and psychosocial conditions must be performed. Nonoperative treatment is primary. Understanding at-risk patients and managing them carefully can decrease disability and improve results following treatment. The results from surgery are less successful in work-related disorders and disability is often prolonged. Surgery should only be performed for clear diagnoses and clear indications after adequate nonoperative treatment, with careful consideration of the job to which the worker will return.

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.

Camitz palmaris longus abductorplasty for severe thenar atrophy secondary to carpal tunnel syndrome.

This is a retrospective review of 29 patients (33 hands) who underwent a palmaris longus transfer because of severe thenar atrophy secondary to median nerve entrapment at the wrist. The mean follow-up was 17 months. Ninety-four percent of our patients were satisfied because their thumb function improved. Twenty-six of the patients had the transfer at the time of initial release of the carpal tunnel, and three patients had the transfer when the carpal tunnel was released a second time. The transfer helps with thumb palmar abduction, and the palmaris longus is an expendable muscle for transfer.

Long-term results after Russe bone-grafting: the effect of malunion of the scaphoid.

Twenty-five patients had Russe anterior corticocancellous bone-grafting between 1973 and 1984 for twenty-six symptomatic established non-unions of the scaphoid. The mean duration of follow-up was eleven years (range, seven to eighteen years). Twenty-one (81 per cent) of the twenty-six scaphoid bones united. We developed two rating scales to evaluate the results of the operation. One scale, based on objective findings, included the radiographic appearance of the wrist, the range of motion, and strength; the other scale, based on subjective findings, comprised function, pain, perception of a decrease in performance because of limitation of motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had a malunion of the scaphoid in which the lateral intrascaphoid angle was more than 45 degrees convex dorsally between the proximal and distal poles (a so-called flexion or humpback deformity, which results in extension of the proximal fragment of the scaphoid at the radiocarpal joint) with the results in patients who had no such deformity. The lateral intrascaphoid angle was more than 45 degrees in thirteen (50 per cent) of the twenty-six wrists. Although the difference in the objective results between the wrists that had a malunion and those that did not have a malunion was highly significant (p = 0.001), there was no significant difference in the subjective results between the two groups, including satisfaction of the patient (p = 0.39). Twenty-three patients (92 per cent) returned to full-time employment and twenty-two (88 per cent), to sports activities. Twenty-three patients (92 per cent) reported that they had pronounced relief of pain and that the procedure had improved their quality of life. The presence of this deformity of the scaphoid after bone-grafting for a symptomatic non-union was not predictive of a poor long-term subjective outcome.

Factors that determine reexploration treatment of carpal tunnel syndrome.

Eighteen patients (20 hands) underwent reexploration of the carpal tunnel after a primary carpal tunnel release. The patients complained of unrelieved symptoms after their initial surgical procedures. We recommend reexploration for patients with unrelieved carpal tunnel syndrome if they have a positive Phalen's test, have symptoms that cause nocturnal wakening or are exacerbated by activities, or have a short or transverse initial incision. If the incision is adequate and these symptoms are not present, we believe that reexploration will not result in a satisfactory outcome.

Reconstruction of the rheumatoid thumb.

Most rheumatoid patients will present with one or more thumb deformities at some stage of their clinical history. The goal of treatment is restoration and maintenance of stable and painless motion. Treatment is based on the type and stage of the deformity. The boutonniere thumb is the most common deformity. Metacarpophalangeal arthrodesis is preferred for isolated metacarpophalangeal involvement. For advanced cases in a low-demand patient, metacarpophalangeal arthroplasty with interphalangeal arthrodesis is performed. In the higher demand hand with an uninvolved carpometacarpal joint, arthrodesis of both metacarpophalangeal and interphalangeal joints may be considered. The less common swan neck is approached by treating the carpometacarpal joint with a hemiarthroplasty or a total resection with capsulodesis or arthrodesis of the metacarpophalangeal joint. Adduction contracture is treated by Z-plasty of the skin of the first web space and release of the adductor aponeurosis. Gamekeeper's deformity is treated with reconstruction of the ulnar collateral ligament. Arthrodesis is recommended for those patients with articular erosion of the metacarpophalangeal joint. Flexor pollicis longus and extensor pollicis longus tendon ruptures are common in rheumatoid patients. Extensor pollicis longus ruptures are usually treated with EIP transfer or observation. Flexor pollicis longus ruptures are more disabling and usually require a tendon transfer, tendon graft, or an interphalangeal joint fusion in patients with radiographic destruction of that joint.

Silicone rubber arthroplasty of the wrist.

The wrist is often referred to as the keystone of the hand. It is often affected in rheumatoid arthritis. Salvage procedures for patients with rheumatoid arthritis involving the wrist include silicone wrist arthroplasty, total joint arthroplasty, and wrist arthrodesis. In 1967, Swanson developed a double-stem, flexible-hinge implant for the radial carpal joint. In 1982, metal titanium bone liners (grommets) were added to help decrease the incidence of fractures. The authors feel that the gold standard is still wrist arthrodesis. However, they would use a flexible wrist arthroplasty in a patient who has bilateral wrist involvement with marked digital deformity and/or proximal interphalangeal stiffness. This is especially true in low-demand patients who have good alignment, good bone stock, and the associated proximal and distal disease. If these criteria are met and meticulous technique used, successful reconstruction of the wrist with a flexible wrist silicone implant can be performed in the patient with rheumatoid arthritis.

Boutonniere rheumatoid thumb deformity.

The boutonniere deformity is the most common rheumatoid thumb deformity. It can be classified into early, moderate, and advanced types, depending on whether the deformity is passively correctable. Fifty-three patients with 74 procedures form the basis of these recommendations. The early type treated with metacarpophalangeal joint synovectomy and extensor pollicis longus rerouting have a high recurrence rate of 64%. Metacarpophalangeal joint fusion is the procedure of choice for the moderate type with isolated metacarpophalangeal joint involvement. Metacarpophalangeal joint arthroplasty is best suited for the low-demand, older patients with borderline proximal and distal joints. Interphalangeal joint releases done with metacarpophalangeal joint fusions have a high recurrence rate and are not recommended. In advanced cases metacarpophalangeal joint arthroplasty and interphalangeal joint fusion is our procedure of choice.

Nonoperative treatment of anterior interosseous nerve paralysis.

Although the current recommendation for the treatment of spontaneous anterior interosseous nerve paralysis is surgical decompression, there has been recent evidence in the neurologic literature that these lesions are examples of a neuritis. We followed 10 cases of spontaneous partial anterior interosseous nerve paralysis. All patients were seen initially with a typical history of pain. Seven had signs of other nerve involvement either on physical examination or electromyogram analysis. Eight patients treated by observation had signs of recovery in 6 months and full recovery within 1 year. Surgical decompression did not affect recovery time in the other patients. Our findings suggest that anterior interosseous nerve paralysis is a form of neuritis and can safely be treated without operation. These patients will achieve complete recovery.

Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow.

Decompression of the ulnar nerve at the elbow with medial epicondylectomy was done in 43 patients and reviewed with an average follow-up of 2.3 years. Eight were graded as excellent, 23 as good, 9 as fair, and 3 as poor results. A special emphasis was placed on analysis of the potential disadvantages of medial epicondylectomy including bone tenderness at the osteotomy site, vulnerability of the ulnar nerve, ulnar collateral ligament instability, and weakness from disruption of the flexor pronator origin. Clinical assessment of strength including quantitative measurement of pinch strength, grip strength and endurance, and testing of forearm muscles did not show these potential disadvantages to be significant problems.

Surgical treatment of the boutonniere rheumatoid thumb deformity.

The boutonniere deformity is the most common rheumatoid thumb deformity. Its treatment is based on the type or stage of the deformity. We have reviewed our recent cases which are the basis for our current recommendations. MP joint synovectomy and EPL rerouting have a high recurrence rate of 64 per cent. MP joint fusion is the procedure of choice for the moderate type with isolated MP joint involvement. There is a low incidence of later IP joint collapse. MP joint arthroplasty is best suited for the low-demand, older patient with borderline proximal and distal joints. IP joint releases have a high degree of recurrence and are not recommended. In a low-demand patient with an advanced thumb, MP joint arthroplasty and IP joint fusion are the procedures of choice.

Treatment considerations in the complicated rheumatoid hand.

The rheumatoid patient with complex involvement or multiple deformities of the hand and wrist can be a challenge to the hand surgeon. A systematic and orderly approach is used to formulate and execute a treatment plan that is realistic and that can result in modest, but significant improvement in overall hand function. The evaluation and treatment philosophy which is described can help turn a complicated and seemingly overwhelming situation into smaller components which can be treated in one or more surgical stages.

Flexor tendon ruptures in patients with rheumatoid arthritis.

One hundred fifteen flexor tendon ruptures were reviewed in 43 hands with rheumatoid arthritis, one hand with psoriatic arthritis, and one hand with lupus erythematosis. Ninety-one tendons were ruptured at the wrist, four ruptures occurred at the palm, and 20 ruptures occurred within the digits. At the wrist level, 61 ruptures were caused by attrition on a bone spur and 30 were caused by direct invasion of the tendon by tenosynovium. All ruptures distal to the wrist were caused by invasion of the tendon by tenosynovium. Patients whose ruptures were caused by attrition regained better motion than those whose ruptures were caused by invasion by tenosynovitis; however, motion overall was poor. Patients with isolated ruptures in the palm or at the wrist had the best functional results. Those patients with multiple ruptures within the carpal canal had a worse prognosis. Ruptures of both tendons within the fibro-osseous canal had the worst prognosis. The severity of the patient's disease and the degree of articular involvement had a great effect on the outcome of surgery. Prevention of tendon ruptures by early tenosynovectomy and removal of bone spurs should be the cornerstone of treatment.

Bowstringing as a complication of trigger finger release.

Bowstringing is a rare complication of trigger finger release caused by excessive loss of the proximal pulleys. As the flexor tendon moves away from the center of rotation of the metacarpophalangeal joint, the flexion moment arm is increased. Thus the flexors gain an increased mechanical advantage over the extensors resulting in limited digital extension. We describe a case of severe bowstringing progressing over 9 years resulting in pain, altered digital function, and loss of full extension.