Benign extraosseous cartilage tumours of the hand and wrist.

Benign extraosseous cartilage tumours of the hand and wrist comprise soft tissue chondromas, synovial chondromatosis and tenosynovial chrondromatosis. These tumours can significantly affect patients as they are often painful, functionally limiting and cosmetically displeasing. Although each tumour is generally considered to be a distinct entity, they share radiological and histopathological similarities. Occasionally, all three tumours may be seen in the same patient. This is an important consideration because of the risk of recurrence that may not necessarily occur at the same anatomical site but instead extend to different sites, such as a tendon sheath and/or joint.

Biomechanical comparison of techniques to reduce the bulk of lacerated flexor tendon ends within digital sheaths of the porcine forelimb.

PURPOSE: Zone II flexor tendon repairs may create a bulging effect with increased bulk and resistance to tendon gliding. A biomechanical time 0 study was performed to assess 2 methods of tendon antibulking for work of flexion and strength characteristics. METHODS: We placed 24 fresh-frozen porcine forelimb tendons in a custom jig. Deep flexor tendon was sectioned just distal to the intact A1 and A2 pulleys. Specimens were divided into 3 groups before repair: group 1, nonmodified tendon; group 2, 30 degrees bilateral notch excised from both tendon ends; and group 3, triangular longitudinal central wedge excised from both tendon ends. All repairs used a 4-strand modified Kessler core suture and running circumferential epitendinous suture. Work of flexion, 2-mm gap formation, and ultimate load to failure were tested. RESULTS: Both antibulking techniques (groups 2 and 3) had significantly less work of flexion than group 1 (36.3 and 34.9 J vs 142.9 J, p < .001). There was no significant change in work of flexion between groups 2 and 3 (p > .05). There was no significant difference in terms of 2-mm gap formation among the 3 groups (p > .05). Groups 1 and 3 exhibited a significantly higher load to failure compared with group 2 (p < .05). CONCLUSIONS: The antibulking repair techniques used in this study decrease the work of flexion with no significant change in force to 2-mm gap formation. Group 2, however, did have significantly lower load to failure. These techniques might be beneficial in zone II flexor tendon injury, in which the tight annular pulley system restricts tendon gliding. However, this is a time 0 study and the potential adverse effects of increase tendon manipulation and trauma were not analyzed, which might increase adhesions and scar during the healing phase of tendon repair.

Intratendinous rupture of a flexor tendon graft many years after staged reconstruction: a report of three cases.

Three cases of rupture of a flexor tendon graft many years after surgery are presented. Two cases occurred 12 years after reconstruction and the third case occurred 21 years after reconstruction. Each rupture was intratendinous, just proximal to the flexor tendon sheath in 2 cases and at the proximal edge of the transverse carpal ligament in the third case. Active digital flexion was restored by transfer of the flexor digitorum superficialis from an adjacent finger to the distal tendon stump or by direct end-to-end repair of the rupture site reinforced with an onlay autogenous patch graft. Patients undergoing tendon grafting should be alerted to the possibility of rupture, even many years later.

Compressive neuropathies of the ulnar nerve at the elbow and wrist.

Compressive neuropathy of the ulnar nerve in the upper limb is a common problem that frequently results in severe disabilities. At the elbow, Lundborg concluded that the nerve was "asking for trouble" because of its anatomic course through confined spaces and posterior to the axis of elbow flexion. Normally, the ulnar nerve is subjected to stretch and compression forces that are moderated by its ability to glide in its anatomic path around the elbow. When normal excursion is restricted, irritation ensues. This results in a cycle of perineural scarring, further loss of excursion, and progressive nerve damage. Initial treatment for the acute and subacute neuropathy at the elbow is nonsurgical. Rest and avoiding pressure on the nerve may suffice, but if symptoms persist, splint immobilization of the elbow and wrist is warranted. For chronic neuropathy associated with muscle weakness, or neuropathy that does not respond to conservative measures, surgery is usually necessary. A variety of surgical procedures have been described in the medical literature, and deciding on the most effective procedure can be difficult considering the excellent results claimed by proponents for each. Unfortunately, there is a paucity of information based on prospective randomized clinical studies comparing the different surgical methods. Dellon attempted to provide some guidelines by reviewing the data in 50 articles dealing with nonsurgical and surgical treatment of ulnar neuropathies at the elbow. In order to provide uniform data, he re-interpreted the data in these articles using his own system for staging nerve compression. He reported that treatment was most successful for mild neuropathies, a conclusion few would challenge. Excellent results were also achieved in 50% of patients with mild neuropathies that were treated nonsurgically and in more than 90% treated by surgery, regardless of the procedure. For moderate neuropathies, nonsurgical treatment was generally unsuccessful, as were decompressions in situ. Medial epicondylectomies were effective in only 50% of cases and they had the highest recurrence rate. Regarding ulnar nerve transpositions, each method has its proponents, usually based on the training and experience of the surgeon. Subcutaneous transposition is the least complicated. It is an effective procedure, particularly in the elderly and in patients who have a thick layer of adipose tissue in their arms. It is the procedure of choice for repositioning the nerve during surgical reductions of acute fractures, arthroplasties of the elbow, and secondary neurorrhaphies. Intramuscular and submuscular transpositions are more complicated procedures. Although proponents of intramuscular transposition report favorable results, the procedure can result in severe postoperative perineural scarring. Submuscular transposition has a high degree of success and is generally accepted to be the preferred procedure when prior surgery has been unsuccessful. I also prefer it as the primary procedure for most chronic neuropathies that require surgery. Compressive neuropathies of the ulnar nerve in the canal of Guyon are less common, but they can also result in significant disabilities. Compression can occur in 1 of 3 zones. Zone 1 is in the most proximal portion of the canal, where the nerve is a single structure consisting of motor and sensory fascicles, and zones 2 and 3 are distal where the ulnar nerve has divided into motor and sensory branches. The clinical picture correlates with the zone in which compression occurs.

Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis.

Ulnar nerve compression at the elbow can occur at any of five sites that begin proximally at the arcade of Struthers and end distally where the nerve exits the flexor carpi ulnaris muscle in the forearm. Compression occurs most commonly at two sites-the epicondylar groove and the point where the nerve passes between the two heads of the flexor carpi ulnaris muscle (i.e., the true cubital tunnel). The differential diagnosis of ulnar neuropathies at the elbow includes lesions that cause additional proximal or distal nerve compression and systemic metabolic disorders. A complete history and a thorough physical examination are essential first steps in establishing a correct diagnosis. Electrodiagnostic studies may be useful, especially when the site of compression cannot be determined by physical examination, when compression may be at multiple levels, and when there are systemic and metabolic problems.

Compressive ulnar neuropathies at the elbow: II. treatment.

Initial treatment of most compressive neuropathies at the elbow is nonoperative, consisting of rest, avoidance of elbow flexion, and, when necessary, temporary immobilization of the elbow and wrist. If symptoms persist, particularly when accompanied by muscle weakness, surgery is usually indicated. Operative procedures include decompression without transposition of the nerve (in situ or by means of medial epicondylectomy) and decompression with transposition of the nerve carried out in a subcutaneous, intramuscular, or submuscular fashion. The indications, advantages, disadvantages, and surgical technique of each operative procedure are discussed.

The role of MR imaging in the management of elbow problems.

In the past several years, the role of MR imaging in diagnosing pathologic conditions of the elbow has dramatically increased. Aside from imaging soft-tissue tumors, it can accurately visualize partial and complete tears of tendons and ligaments, as well as displacement of epiphyseal fractures in children. Its role in identifying loose bodies, particularly when they are nonosseous, and areas of osteochondritis dissecans has also increased. The use of MR imaging for diagnosing neuropathies, particularly when electrodiagnostic studies are negative, offers exciting possibilities as additional technical improvements are developed.

Hand and wrist disorders: how to manage pain and improve function.

Pain, swelling, or impaired function of the hand or wrist may be the result of one of several chronic or acute conditions, including tendinitis, arthritis, infection, or trauma. The first step in diagnosing a hand or wrist disorder is a detailed history. Include a review of the medical history, as many systemic disorders (eg, psoriasis, diabetes mellitus, rheumatoid arthritis, and scleroderma) may affect the hand and wrist. In the physical exam, assess motions of the cervical spine and those of all joints in the symptomatic extremity. A simple neurologic evaluation is required to assess function of the major nerves in the upper extremity. X-rays are indicated in any patient with hand or wrist pain.

Comparison of a suture technique with the modified Kessler method: resistance to gap formation.

We performed an in vitro study using canine flexor tendons to compare the tensile properties of a suture technique for flexor tendon repair with the standard modified Kessler technique. The technique employs a central wire loop that connects the two transverse limbs of the modified Kessler suture. Both techniques were studied with and without a Lembert epitendinous stitch. The technique combined with an epitendinous suture provided the strongest resistance to gap formation, and its load at gap initiation was 100% greater than the load in tendons repaired with the modified Kessler and an epitendinous suture. Because of its increased resistance to gap formation, this suture technique may provide a safer margin for controlled early active motion after flexor tendon repair.

Arteriovenous shunt as a method of restoring venous drainage in rabbit ear replantation.

An arteriovenous (AV) shunt as a method of restoring venous drainage during replantation was examined by use of the rabbit ear model. The results were compared to ears replanted using one vein (1:1) or two veins (2:1) for venous drainage. The success rate for AV shunt replantations was found similar to that of replantations with a 1:1 ratio, but lower than that of ears with a 2:1 ratio. Postoperatively, ears replanted using an AV shunt or a 1:1 ratio revealed more swelling and lower tissue oxygenation than ears with a 2:1 ratio. After 10-14 days, all ears that survived were similar in appearance, regardless of method of replantation. Microscopic venules crossing the replanted interface appeared at seven days following surgery in all groups. The authors conclude that the AV shunt method offers an alternative to venous anastomosis when vein-to-vein reconstruction cannot be established.

[Trispiral tomography and magnetic resonance imaging of the wrist joint]. / Trispiraltomographie und Magnetic Resonance Imaging des Handgelenks.

Tomography and magnetic resonance imaging (MRI) are important imaging techniques in the diagnosis and management of a wide variety of wrist disorders. They have been useful for evaluating fractures, tumors, arthritic conditions and avascular necrosis involving the carpal bones as well as injuries affecting the radiocarpal and intercarpal ligaments and the triangular fibrocartilage complex. The indications and clinical applications of each imaging technique will be discussed.

Trispiral tomography and magnetic resonance imaging of the wrist.

Tomography, which permits a far more accurate visualization of lesions than conventional radiographs, is conducted via several different methods, depending on the specific movement of the x-ray tube. Linear tomography is the simplest method but produces images that appear streaked. Zonotomography, which uses an elliptical or figure-8 movement of the x-ray tube, creates a uniform blurring of structures and a much clearer resolution of the plane of focus. Even sharper images are produced by multidirectional trispiral tomography, which is described as well as its application to specific anatomic areas of the wrist. The normal anatomy and a variety of problems of the wrist as visualized with magnetic resonance imaging are also described.

Lunate-triquetral and midcarpal joint instability.

Instability of the ulnar side of carpus centers around the triquetrum, which is suspended by the ulnar triquetral ligaments and supported proximally by the TFCC. The triquetrum guides the lunate by an interosseous membrane and stout palmar ligaments that provide a relatively rigid connection between the two bones. Disruption of the LT ligament is frequently associated with pathology in the ulnar carpal area and may progress to triquetral instability, VISI, and finally, degenerative arthritic changes on the ulnar side of the carpus. The diagnosis of LT injuries is made by stress radiographs, arthrography, video-fluoroscopy, and arthroscopy. Treatment is initially nonoperative, but if symptoms persist, surgery is warranted. Arthroscopic debridement and pinning the LT joint, ligament repair or reconstruction, and intercarpal arthrodesis have all been reported as successful treatments. For the chronic problem confined to the LT joint, a limited intercarpal arthrodesis of the joint is the most predictable procedure for relieving pain without causing any significant restrictions in wrist motions. When there is a dissociation pattern in addition to LT instability, a more extensive intercarpal arthrodesis is required. Midcarpal instability occurs at the triquetral-hamate joint and is characterized by a dynamic subluxation of the joint. During ulnar deviation, the joint undergoes an exaggerated shift from volar flexion to dorsiflexion. Supportive care is generally successful; although in chronic cases, a midcarpal joint arthrodesis is often required.

Metacarpophalangeal joint injuries of the thumb.

Dorsal capsular injuries, volar plate injuries, ulnar collateral ligament injuries, and radial collateral ligament injuries are all discussed in this article. Treatment is both discussed and illustrated for ease of comprehension.

The effects of scaphoid intercarpal stabilizations on wrist mechanics: an experimental study.

A fresh cadaver study of the effects of a variety of scaphoid stabilizations on wrist motions is reported. Scaphoid-trapezium-trapezoid stabilizations with the scaphoid in its normal anatomic position and the same stabilizations with the scaphoid in malposition, either vertical or horizontal in relation to the radius, were compared. Scaphoid-capitate stabilizations with the scaphoid in its normal position were also studied. With the scaphoid vertical, a scaphoid-trapezium-trapezoid stabilization resulted in greater loss of wrist flexion and ulnar deviation whereas, with the scaphoid horizontal, wrist extension and radial deviation were more severely affected than when the scaphoid was stabilized in its normal position. With the scaphoid in its anatomic position, both scaphoid-trapezium-trapezoid and scaphoid-capitate stabilizations resulted in similar patterns of wrist motion.