Ulnar nerve dislocation and snapping triceps syndrome: diagnosis with dynamic sonography--report of three cases.

Initial experience with the use of dynamic sonography of the elbow for diagnosing ulnar nerve dislocation and snapping triceps syndrome is reported. Cases of three consecutive patients who underwent sonographic evaluation of the elbow and subsequent open elbow surgery for symptomatic ulnar nerve dislocation were reviewed. Dynamic sonography of the elbow was used to aid in the accurate diagnosis of and differentiation between ulnar nerve dislocation and snapping of the medial triceps muscle.

Wrist arthrodesis: review of current techniques.

Wrist arthrodesis is a well-established procedure that predictably relieves pain and provides a stable wrist for power grip. Although a variety of techniques for achieving a solid fusion have been described, the combination of rigid stabilization with a dorsal plate and autogenous cancellous bone grafting results in a high fusion rate and obviates the need for prolonged postoperative cast immobilization. Successful results with dorsal plating with or without local bone graft have recently been reported for patients with posttraumatic conditions. Rod or pin fixation is an established procedure for patients with inflammatory arthritis or a connective tissue disorder; however, plate fixation for these conditions is becoming a more acceptable alternative. Complications are relatively common and range from minor transient problems to major problems, such as wound dehiscence, infection, extensor tendon adhesions, and plate tenderness, which may require implant removal. Preoperatively, patients should be assessed for the presence of carpal tunnel syndrome, distal radioulnar joint arthritis, or ulnocarpal impaction syndrome, which may become or remain symptomatic after arthrodesis. Wrist arthrodesis results in a high degree of patient satisfaction with respect to pain relief and correction of deformity. Patients are able to accomplish most daily tasks and activities by learning to adapt to, and compensate for, the loss of wrist motion.

Ulnar translocation instability of the carpus after a dorsal radiocarpal dislocation: a case report.

An unusual case of ulnar translocation of the carpus after a radiocarpal dislocation is described. Persistent instability was noted despite attempted reattachment of the avulsed palmar capsuloligamentous structures. A successful outcome occurred after radiolunate arthrodesis and external fixation of the wrist.

The effect of knee and ankle position on displacement of Achilles tendon ruptures in a cadaveric model. Implications for nonoperative management.

Using a cadaveric model, we evaluated the effect of knee and ankle position on the displacement of the severed ends of an Achilles tendon transected at three different points. In six cadaveric legs the Achilles tendon was severed transversely, then marked with radiopaque wire suture. The distance between the wire markers was measured on radiographs taken in different positions of ankle and knee flexion. Ankle plantar flexion had a statistically significant effect on decreasing the gap between the severed ends of the Achilles tendon. This effect was clinically significant as, on average, the tendon edges were separated more than 20 mm when the ankle was in the neutral position and were apposed when the ankle was in 60 degrees of plantar flexion. With the ankle fixed in 60 degrees of plantar flexion, knee position had no significant effect on the displacement of the severed ends of the Achilles tendon. Overall, the effect of knee flexion was neither statistically significant nor clinically significant, as the increase in displacement of the severed ends of the Achilles tendon was only 3 mm from 0 degrees to 120 degrees of knee flexion. These results suggest that the nonoperative treatment of Achilles tendon ruptures requires immobilization in maximal ankle plantar flexion, and that immobilization of the knee may not be necessary to achieve tendon-edge apposition.

The evolution of the distal radio-ulnar joint.

The pectoral girdle and the distal radio-ulnar joint have evolved over a period of 400 million years. Clinical circumstances exist that may represent atavistic development in modern man. Current understanding of this complex area does not explain all clinical situations.

Mimickers of hand infections.

A variety of local or systemic conditions may mimic an infectious process in the hand and upper extremities. Familiarity with these conditions is important so that appropriate diagnosis and management may ensue. Most of the conditions presented in this article may be successfully managed nonsurgically; however, certain conditions such as the extravasation of a chemotherapy agent or retained foreign body require surgical intervention.

Infections of the fingertip. Paronychias and felons.

Paronychias and felons are the most commonly encountered hand infections. Successful management of an uncomplicated infection involves an accurate diagnosis and prompt initiation of treatment, consisting of the judicious use of an appropriate incision, wound drainage, local wound care, antistaphylococcal antibiotics, and early rehabilitation. Complicated infections occur in immunosuppressed patients or those whose infection has been neglected or mistreated. Treatment of such infections is individualized.

Deep subfascial space infections.

Infections of the deep subfascial spaces of the hand and wrist are relatively uncommon but well recognized. Potential sites for infection include the interdigital web space, dorsal subaponeurotic space, Parona's space, thenar space, midpalmar space, and hypothenar space. Treatment involves surgical drainage in combination with appropriate systemic antibiotics. Several alternative surgical approaches have been described. Selection is based on the extent and precise location of the infection and surgeon preference. Aggressive hand therapy usually is required in the postoperative period to avoid the complication of tendon adhesions, joint contractures, and hand stiffness. With early recognition and expedient surgical treatment, a satisfactory outcome can be expected for those infections that occur in otherwise healthy, nonimmunocompromised patients.

Nail gun injuries of the hand.

Nail gun injury of the hand is commonly encountered among workers in the construction industry. Successful management requires a thorough understanding of this unique injury, the recognition of nail shaft barbs, and appropriate nail removal and wound care, with referral when indicated. If barbs are encountered, nail removal involves cutting off the head of the nail and extracting the nail in the direction of entry.

Radial tunnel syndrome: long-term results of surgical decompression.

Between 1980 and 1990, 31 patients (33 extremities) underwent decompression of the radial tunnel. All procedures were performed at the same institution by the senior author using a brachioradialis muscle-splitting approach. Twenty-three patients (24 extremities) were available for follow-up evaluation at an average of 8 years after surgery. The outcome was determined using the original criteria of Roles and Maudsley and Ritts et al. By the criteria of Roles and Maudsley, outcomes for 15 patients (16 extremities; 67%) were rated as excellent/good and for 8 patients (8 extremities; 33%), as fair/poor. By the criteria of Ritts et al., 16 patients (17 extremities; 71%) had good results and 7 patients (7 extremities; 29%), a fair/poor result. Overall, the majority of patients were satisfied and felt helped by the surgery. Five patients changed their occupation because of continued discomfort. Significant differences in outcome were not found for workers' compensation patients. Similarly, no differences in outcome were found for site of compression, patient sex, history of trauma, or associated neuropathies. The results of this study suggest that complete pain relief and return to activities following radial tunnel surgery is not as predictable as previous studies have indicated. Nineteen patients (20 extremities), however, felt satisfied and helped and believed they gained improved function because of surgical decompression of the radial tunnel.

Fibrous hamartoma of infancy in the hand: a case report.

Fibrous hamartoma of infancy (FHI) is a rare, benign tumor. The proximal upper extremity is most commonly involved. A previously unreported case of FHI in the hand is presented.

Correction of malunited Bennett's fracture by intra-articular osteotomy: a report of two cases.

Two young male laborers had a corrective intra-articular osteotomy for a symptomatic malunited Bennett's fracture. Follow-up examination at 24 and 40 months, both patients experienced dramatic pain relief and improved thumb range of motion, and grip, and pinch strengths. A corrective intraarticular osteotomy is an acceptable alternative to arthrodesis or arthroplasy in select patients with a malunited Bennett's fracture.