Flexor Tendon Attritional Ruptures Following Distal Radius Volar Plate Fixation.

PURPOSE: To investigate patient and radiographic factors that may correlate with the time to flexor tendon rupture following volar plate fixation of distal radius fractures. METHODS: A total of 31 patients who underwent volar plate removal because of flexor tendon rupture were analyzed. Patient demographics and the interval from operative fixation until rupture were determined retrospectively. Volar tilt and lateral carpal alignment were measured radiographically. The Soong classification was used to grade volar plate prominence. The correlation between the duration to tendon rupture and volar tilt, carpal alignment, and age was evaluated. RESULTS: There were 7 men and 24 women. Mean age at the time of hardware removal and flexor tendon management was 66 years (n = 31). Radiographs were classified as Soong 1 (n = 24) and Soong 2 (n = 3). The mean measured volar tilt was -4° (range, -20°-+7°). The mean interval from operative fixation until complete tendon rupture was 4.9 years, (range, 0.3-13.1 years; n = 30). There was no correlation between the time interval to rupture and the magnitude of tilt, carpal alignment, or age at the time of operative fixation. CONCLUSIONS: Although volar plate prominence was present in all patients with flexor tendon ruptures, radiographic parameters including the degree of dorsal tilt, lateral carpal alignment, and patient age did not correlate with the time interval from fixation to tendon rupture. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Managing Challenges in Thumb Carpometacarpal Arthritis.

Thumb carpometacarpal osteoarthritis is commonly encountered and multifactorial in etiology, and its management is based on the radiographic stage and surgeon preference. A variety of management strategies exist including ligament reconstruction, arthroscopic débridement, extension osteotomy, open versus arthroscopic total and partial trapeziectomy with or without interposition and/or suspensionplasty, arthrodesis, and total or hemi implant arthroplasty. A review of the literature shows each of these management strategies to be effective in pain relief, but no one procedure has been shown to be superior despite theoretic benefits to preserving trapezial height. The one common denominator is removal of the arthritic contact between the thumb metacarpal and trapezial surfaces.

Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome.

In addition to the more common carpal tunnel and cubital tunnel syndromes, orthopaedic surgeons must recognize and manage other potential sites of peripheral nerve compression. The distal ulnar nerve may become compressed as it travels through the wrist, which is known as ulnar tunnel or Guyon canal syndrome. The posterior interosseous nerve may become entrapped in the proximal forearm as it travels through the radial tunnel, which results in a pain syndrome without motor weakness. The median nerve may become entrapped in the proximal forearm, which can result in a variety of symptoms. Spontaneous neuropathy of the anterior interosseous nerve branch of the median nerve can be observed without external compression. Electrodiagnostic and imaging studies may aid surgeons in the diagnosis of these syndromes; however, a thorough physical examination is paramount to localize compressed segments of these nerves. An understanding of the anatomy of each of these nerve areas allows surgeons to appreciate a patient's clinical findings and helps guide surgical decompression.

Forearm instability.

Forearm instability results from trauma, which disrupts the radial head, the interosseous membrane, and the triangular fibrocartilage complex. Inadequate treatment of injuries to these forearm stabilizers may result in the complex problem of chronic longitudinal forearm instability. Delayed recognition and/or treatment of injuries producing forearm dissociation has led to poor patient outcomes, which makes timely recognition of the injury pattern imperative. This article discusses relevant aspects of forearm anatomy and current concepts in the diagnosis and treatment options for this complex injury pattern.

Simple medial elbow dislocations: a rare injury at risk for early instability.

PURPOSE: To report the presentation, treatment, and outcomes of a series of simple medial elbow dislocations and to identify features distinguishing this injury from the more common dislocation patterns. METHODS: From 2000 to 2011, 4 cases of simple medial elbow dislocations were treated at a single referral center. Retrospective review was conducted to evaluate presentation, treatment, and outcomes. RESULTS: The mean patient age was 56 years (range, 49-61 y). All dislocations were in the nondominant arm of women after a fall from standing height. Two elbows had immediate closed reduction, and 2 elbows could not be reduced acutely. All elbows presented within 2.5 weeks of injury with recurrent instability or dislocation. Two patients also had acute symptoms of ulnar neuropathy. All patients had surgical repair of the lateral collateral ligament complex and extensor tendon origin. Three patients had ulnar nerve decompressions. All elbows were stable to valgus, varus, and rotatory stress testing, with no subjective instability at a minimum follow-up of 8 months (range, 8-144 mo). Three patients reported no pain. Symptoms of ulnar neuropathy resolved in all patients. Mean elbow range of motion was from 13° to 135° of extension/flexion, with full pronation and supination. CONCLUSIONS: Simple medial elbow dislocations may be at risk for early instability and may represent a more noteworthy soft tissue injury than typical dislocation patterns. Surgical treatment of early instability in these injuries led to acceptable patient outcomes.

Flexor Tendon Reconstruction.

Chronic injury to the flexor tendon system of the hand remains a challenging problem for the hand surgeon to treat. Both single- and two-stage techniques remain important in the reconstruction of the flexor tendon deficient digit. Modern advances include the use of allograft composites that aim to reduce the time and donor-site morbidity compared with conventional autograft techniques. Regardless of technique, restoring a gliding tendon-pulley system with a functional arc of motion is the primary goal of flexor tendon reconstruction.

Failed Triangular Fibrocartilage Complex Repair and Reconstruction.

Unsuccessful triangular fibrocartilage complex (TFCC) repair or reconstruction is poorly defined, often stemming from multiple causes, both patient and surgeon-related. Complete evaluation of the patient's psychosocial status and involvement in any litigation claims is essential, as is a thorough history, physical examination, and imaging workup to accurately diagnose TFCC injury, along with any concomitant wrist pathology. Awareness of common complications and technical errors is critical, and preventive treatment strategies should be implemented to minimize these events.

Mycobacterial Infections in the Hand and Wrist.

Mycobacterial hand infections are uncommon. These infections have an indolent course and are marked by variable and nonspecific presentations, often leading to diagnostic and treatment delays. The pathogens involved in mycobacterial hand infections include Mycobacterium tuberculosis complex, atypical mycobacteria, and M leprae. Initial treatment involves a combination of long-term antibiotics and surgical débridement to cure the infection. Reconstructive procedures aid in restoring hand function lost secondary to the disease.

Forearm instability.

Forearm instability is a complex problem resulting from traumatic disruption of the forearm stabilizers: the radial head, the interosseous membrane, and the triangular fibrocartilage complex. Dissociation of the forearm unit is often underrecognized and therefore inadequately treated, leading to poor patient outcomes. The goals of this article are to impart an understanding of the forearm anatomy and the current concepts in the diagnosis and treatment options for this complicated problem.

Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome.

In addition to the more common carpal tunnel and cubital tunnel syndromes, orthopaedic surgeons must recognize and manage other potential sites of peripheral nerve compression. The distal ulnar nerve may become compressed as it travels through the wrist, which is known as ulnar tunnel or Guyon canal syndrome. The posterior interosseous nerve may become entrapped in the proximal forearm as it travels through the radial tunnel, which results in a pain syndrome without motor weakness. The median nerve may become entrapped in the proximal forearm, which can result in a variety of symptoms. Spontaneous neuropathy of the anterior interosseous nerve of the median nerve can be observed without external compression. Electrodiagnostic and imaging studies may aid surgeons in the diagnosis of these syndromes; however, a thorough physical examination is paramount to localize compressed segments of these nerves. An understanding of the anatomy of each of these nerve areas allows practitioners to appreciate a patient's clinical findings and helps guide surgical decompression.

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis.

In patients with rheumatoid arthritis, metacarpophalangeal joint deformities can significantly affect hand function. Flexible hinge implant arthroplasty, designed in the 1960s, remains the most accepted and widely performed technique for treatment of severely involved metacarpophalangeal joints in rheumatoid arthritis. An arc of motion of 40 degrees to 60 degrees can be expected after arthroplasty, with improvement of finger extension and ulnar deviation. Silicone implant arthroplasty, although technically challenging, is the standard surgical procedure for improving hand function in these patients. Complications include recurrent ulnar deviation, extensor lag, implant fracture, infection, and silicone-induced particulate synovitis. Despite these limitations, patient satisfaction is high with enhancement of hand appearance and function and relief of pain.

Examining the efficacy and maintenance of contracture correction after collagenase clostridium histolyticum treatment for Dupuytren's disease.

BACKGROUND: This study examined the efficacy, complications, and contracture recurrence in patients who received injectable collagenase clostridium histolyticum (CCH) for Dupuytren's-induced metacarpophalangeal (MP) and proximal interphalangeal (PIP) joint contractures. METHODS: A retrospective chart review at one center compared the degree of MP and PIP joint contracture pre-injection, post-cord rupture, and at final follow-up after a minimum duration of 6 months. Recurrence was defined as a 20 ° or greater increase in contracture above the minimum value achieved. RESULTS: Of 102 eligible patients, 48 patients (47 %) (31 males, 17 females) were available for review. 53 digits and 64 joints (46 MP joints and 18 PIP joints) were studied. The mean patient age was 66 years (range, 48-87 years) and mean follow-up duration was 15 months (range, 6 to 25 months). The mean MP joint contracture was 51 ± 20 ° at baseline, 4 ± 8 ° post-cord rupture, and 9 ± 15 ° at latest follow-up. The mean PIP joint contracture was 39 ± 23 ° at baseline, 14 ± 14 ° at cord rupture, and 29 ± 20 ° at latest follow-up. Of the 46 MP joints and 18 PIP joints, 11 MP (24 %) and 7 (39 %) PIP joints met the recurrence criteria. Of 102 patients, 1 patient had a small finger flexor tendon rupture. CONCLUSIONS: Despite the dramatic initial reduction in contracture, recurrence developed in a high proportion of patients over the study period. While initially effective, CCH may not provide durable contracture reduction. However, CCH remains a viable nonsurgical treatment for Dupuytren's disease.

Flexor tendon rupture caused by gout: a case report.

We present a case of primary gouty infiltration of flexor tendons in the hand, causing rupture of both flexor digitorum superficialis and profundus tendons in a single digit. The patient was managed by a single-stage reconstruction of the less involved flexor digitorum superficialis tendon using a segment of the proximal stump of flexor digitorum profundus tendon as a bridge graft. This uncommon etiology of tendon rupture should be considered in all patients with a history of gout presenting with tendon insufficiency.