Traumatic combined radial and ulnar axial wrist dislocation.

In axial wrist dislocation, the proximal and distal transverse arches are disrupted and the carpus and metacarpal bases are split longitudinally. Early reduction and stabilization of the dislocation combined with exploration and decompression provide the best results.

The arthroscopic management of intra-articular distal radius fractures.

Intra-operative arthroscopy and fluoroscopy provide improved visualisation and guide the restoration of intra-articular distal radial fractures while minimising the operative dissection required for their stabilisation. Radial styloid fractures, distal radial fractures with dorsal, palmar or combined ulnar-sided "die punch" fragments, palmar and dorsal Barton's fractures, and various three- and four-part intra-articular fractures without significant bone loss or defect are especially suited for this technique. The experienced arthroscopist may wish to apply the technique to more severely comminuted intra-articular fractures. Bone defects may be approached through a limited dorsal incision traversing the 3rd dorsal wrist compartment. Arthroscopy and fluoroscopy may be used adjunctively to assess fracture reduction and fixation. Arthoscopy further facilitates initial treatment by allowing direct joint visualisation, debridement, the removal of small free intra-articular fragments, and the recognition and early treatment of wrist ligament injuries, particularly those not appreciated by X-ray evaluation

Early wrist arthrodesis for irreparable intra-articular distal radial fractures.

When articular restoration and congruity cannot be accomplished in distal radial fractures owing to severe articular bone loss or comminution, early wrist arthrodesis should be considered. This procedure rapidly restores wrist alignment and stability and controls pain. Arthrodesis is a highly reliable and definitive procedure that optimises the opportunity for early functional and occupational recovery while minimising the risks of developing stiff digits or chronic pain in injuries otherwise doomed from the start of treatment to result in severe wrist stiffness and post-traumatic arthritis. Simultaneous proximal row carpectomy or the use of ipsilateral local bone graft donor sites, such as the distal radius or proximal ulna, decrease both initial treatment and hospital costs and morbidity. Wrist arthrodesis is also effective when polytrauma or multiple fractures co-exist. Successful early treatment may expedite return to work and reduce lost time and wages resulting from the injury.

Arthroscopic management of intra-articular distal radius fractures.

Wrist arthroscopy is increasingly becoming recognized as an important adjunct in the management of displaced intra-articular fractures of the distal radius. Anatomic restoration of the articular surface is possible under bright, magnified conditions. Osteochondral loose bodies and associated intracarpal soft tissue injuries that may not be apparent on plain radiographs are detected and simultaneously managed. A method of management for displaced distal radius fractures using wrist arthroscopy and a combination of percutaneous and limited open reduction techniques are described.

Osteomyelitis of the hand.

Osteomyelitis involving the tubular bones of the hand is a rare and potentially devastating disease. An early and accurate diagnosis combined with aggressive surgical debridement and appropriate antibiotics remains the cornerstone of treatment. This article reviews current principles involving the etiology, pathophysiology, diagnosis, and treatment of osteomyelitis of the hand.

Biochemical and histological analysis of the flexor tenosynovium in patients with carpal tunnel syndrome.

Carpal tunnel release is the most common hand operation performed in this country. In the absence of specific systemic diseases, the etiology and persistence of pain and dysfunction even after surgical decompression is poorly understood. The focus of this investigation was to investigate the biological factors present within the patients serum that may lead to increased sensitivity to pain. Tissue was collected from patients during surgery. The tissue was homogenized and the homogenate analyzed for the presence of IL-1, IL-6, prostaglandin E series (PGE2). The levels were compared with volunteers that had no evidence of carpal tunnel syndrome or pain. The results showed similar levels of IL-1 (range 42-26 ng/ml) in tissue homogenates, and a significant increase in levels of IL-6 and malionaldehyde bis-(diethyl acetal) in CTS patients in comparison to control tissues. This increase may be associated with oxidative changes occurring as a result of ischemia and reperfusion. Tissue homogenates were also evaluated for PGE2. The CTS tissues showed a five fold elevation in PGE2 compared to control tissues. Levels of PGE2 in CTS tissues were statistically different using a two-tailed student T-test. Increased levels of PGE2 can enhance vascular permeability at the site of injury, and can play an important role in activating adenylate cyclase which increases intracellular cyclic adenosine monophosphate (cAMP). This increase in cAMP levels can inhibit functional responses to other inflammatory stimuli. Increases in PGE2 can also cause sensitization of the nerve endings so that a normal stimulus that would not necessarily cause pain will now be experienced as painful. The results of this study demonstrate that arachidonic acid metabolites PGE2 may be responsible for both the pathological changes and clinical symptomatology in carpal tunnel syndrome.

Arthroscopically assisted reduction of intraarticular distal radial fractures.

Anatomic restoration of the joint surface and extraarticular alignment is the goal in management of displaced distal radial fractures. Arthroscopy provides well lit, magnified conditions in which to reconstruct the fractured joint surface and to detect and manage intracarpal soft tissue injures associated with distal radial fractures. Percutaneous and limited open reduction techniques combined with wrist arthroscopy in the arthroscopically assisted management of displaced distal radial fractures is described.

Early salvage reconstruction of severe distal radius fractures.

During an 8-year period from 1980 through 1988, 9 distal radius fractures could not be restored because of bone loss or extensive comminution and were, therefore, salvaged by early arthrodesis in 7 patients and Swanson silicone wrist arthroplasty in 2. At a mean of 3.7 years, 4 patients rated good, 2 satisfactory, and 3 poor according to a 100-point scoring system based on residual pain, motion, grip strength, and occupational recovery. Irreparable distal radial fractures with damage largely confined to the skeleton achieved satisfactory or good results. Poor results occurred when there was severe soft tissue damage, especially neurovascular injury, despite a successful skeletal reconstruction. When articular restoration could not be accomplished, early arthrodesis or arthroplasty resulted in wrist alignment, stability, and pain control, and optimized the opportunity for digital and upper extremity functional recovery.

Use of the minicondylar plate in metacarpal and phalangeal fractures.

The minicondylar plate is used for unstable intraarticular and periarticular fractures of the phalanges and metacarpals to provide stability and to allow early motion. This low profile implant can be placed laterally to avoid injury to the extensor mechanism. The authors retrospectively reviewed 53 consecutive patients from 2 institutions in whom 68 fractures (41 metacarpal and 27 phalangeal) had been treated with 1.5-mm or 2-mm minicondylar plates. Common mechanisms of injury were gunshot wounds, crush injuries, and assault/beatings. Thirty-seven fractures were open, 19 had severe soft tissue injury, and 30 required a bone graft. The followup period averaged 17 months. There were no nonunions or malunions. Sixty-seven complications were associated with 40 fractures in 29 patients: primarily symptomatic plates or pullout (30 complications), extensor lag (13 complications), and infections (8 complications). The complication rate was significantly higher in intraarticular and periarticular fractures also involving the middle 1/3 versus proximal 1/3 fractures; open versus closed fractures; fractures with increased soft tissue injury versus minimal injury; and bone grafted versus nongrafted fractures. Final arc of total active motion, available for 45 fractures, was excellent (> or = 221 degrees) for 17 fractures; good/fair (121 degrees to 220 degrees) for 15, and poor (< or = 120 degrees) for 13. Metacarpal fractures had a significantly higher percentage of excellent results than did phalangeal fractures. Final motion did not correlate significantly with complication rate, severity of soft tissue injury, location in the bone, open versus closed fracture, or use of bone graft. When fractures cannot be restored and stabilized reliably by less invasive methods, the minicondylar plate provides secure fixation and can result in adequate function, even in the presence of severe combined injuries.