Pre-operative electrodiagnostic testing predicts time to resolution of symptoms after carpal tunnel release.

UNLABELLED: The purpose of this study was to determine if nerve conduction studies predict time to resolution of symptoms after carpal tunnel release. A total of 56 patients undergoing open carpal tunnel release were prospectively enrolled. Pre-operative presence of nocturnal symptoms and daytime numbness/tingling were documented. Pre-operative nerve conduction studies were reviewed and classified as mild, moderate, or severe. After open carpal tunnel release, patients were contacted by phone within 48 hours, at 1 week, and then at 2-week intervals for up to 9 months or until both nocturnal and daytime symptoms had resolved. This study found that patients with mild or moderate carpal tunnel syndrome experience a faster time to resolution of daytime numbness and tingling when compared with patients with severe carpal tunnel syndrome. Nocturnal symptoms resolved quickly in both groups. The results of this study are in contrast to previous studies that found little to no value of nerve conduction studies in predicting post-operative functional and subjective outcomes. LEVEL OF EVIDENCE: IV.

Interobserver variation in the identification of breast carcinoma in intramammary lymphatics.

Nine surgical pathologists participated in a microscopic review of 35 cases of pT1-2 N0 M0 breast carcinoma. The pathologists outlined strict criteria for the identification of intramammary lymphatics and blood vessels and for the identification of cancerous emboli in these vascular channels. Each mastectomy case was studied by three different pathologists. All three concurred on the presence or absence of intralymphatic cancer in 12 of the 35 cases. Observers agreed on the absence of blood vessel invasion in 30 of the 35 cases. There was no consistent bias on the part of a single reviewer, either alone or with another pathologist, in identifying the emboli. We conclude that the identification of intralymphatic cancerous emboli in mastectomy specimens is not a reliably reproducible prognostic finding on which recommendation of systemic chemotherapy in stage I breast carcinoma patients can be based.

Contact stress distributions in malreduced intraarticular distal radius fractures.

Residual articular incongruity of the distal radius following intraarticular fracture has been correlated with early osteoarthritis (OA) and a poor clinical outcome. We developed a simple in vitro fracture model of the distal radius to investigate the relationship between degree of articular incongruity and the resulting distribution of radiocarpal contact stress. Twelve fresh-frozen cadaver arms were dissected, packets of Fuji Pressensor film were inserted into the wrist, and the wrist was loaded through its flexor and extensor tendons. We created a simple intraarticular fracture that allowed controlled distal radius articular incongruity. Loading trials were performed for the intact distal radius, for a fully reduced case, and for step-offs of 0.4, 1, 2, and 3 mm. Mean contact stress was significantly greater than the anatomically reduced case at only 3 mm of step-off. Contact area was greater than the anatomically reduced case at 0.4, 1, and 2 mm of step-off. The elevations in contact stress that we observed were only modest, suggesting that other factors may be involved in the pathogenesis of radiocarpal OA in the presence of residual articular incongruity.

Radial instability of the metacarpophalangeal joint of the thumb. A biomechanical investigation.

Human cadaver thumbs were tested to evaluate stability of the radial side of the MP joint. The contributions of the dorsal capsule, radial collateral ligament, accessory collateral ligament, and volar plate were examined with the joint in 0 degrees and 30 degrees of flexion. At 0 degrees flexion, the average joint angulation increased 4 degrees following isolated radial collateral ligament transection and 6 degrees following isolated accessory collateral ligament transection. Release of both the accessory and radial collateral ligaments produced marked instability with joint angulation of at least 46 degrees. The accessory collateral ligament helped to stabilize the extended MP joint. There were no significant contributions to stability from the dorsal capsule and volar plate when the collateral ligaments were intact. In the laboratory setting, radial-side instability of the MP joint of the thumb requires transection of both the proper and accessory radial collateral ligament.

The treatment of chronic traumatic subluxation of the distal ulna by hemiresection interposition arthroplasty.

Dorsal and palmar subluxation of the distal ulna can be difficult to both diagnose and treat. Patients often present long after their initial injuries with posttraumatic arthritic changes in the distal radioulnar joint. Hemiresection interposition arthroplasty is a salvage procedure that is reliable for both pain relief and restoration of motion.

Radioulnar joint fusion for distal radioulnar joint instability.

Each one of this small group of patients illustrates a rare indication for the radioulnar joint fusion procedure in distal radioulnar joint instability. The case histories tell of a last ditch effort to salvage function in an extremity crippled by painful radioulnar instability after excision of the distal ulna. The fusions healed slowly and two required repeat surgery to achieve union. Today we would routinely add iliac bone graft to the fusion area to hasten healing. Rarely indicated, this is a salvage procedure that is done after failure of other procedures geared to preserve the rotation of the forearm. These patients all had successful salvage of their extremities for activities of daily living, but only one returned to his labor job. All were worker's compensation cases in physical jobs. Two patients had had prior radiocarpal fusions, making them even more restricted in function. This procedure should be kept in mind to be used in the rare cases of painful instability of the distal radioulnar joint when traditional motion-preserving procedures have failed.

Secondary flexor tendon reconstruction.

Staged flexor tendon reconstruction using silicone rods is a technique that can be successfully used to salvage severely injured digits. Refinements in the technique have led to the development of an active tendon prosthesis which is under clinical investigation. Attention to technical details and a well-supervised rehabilitation program are necessary to obtain satisfactory results.

Aberrant lumbrical muscles causing carpal tunnel syndrome.

Two cases of carpal tunnel syndrome secondary to an abnormally proximal origin of the lumbrical muscles are presented. Division of the transverse carpal ligament and neurolysis of the median nerve was performed in both cases, resulting in complete relief of symptoms. The anomalous lumbrical muscle bellies were not resected.

A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist.

This retrospective study compared plate fixation versus pin fixation in 57 patients with rheumatoid arthritis who underwent wrist arthrodesis. Fixation was achieved by using plates in 32 patients and longitudinal pins in 25 patients. Clinical follow-up averaged 29 months (range: 12-57 months) and radiographic follow-up averaged 16 months (range 12-39 months). Union occurred in 97% of the wrists fixed with plates and in 96% of the wrists fixed with pins. There were 6 (19%) complications in the plate group and 7 (28%) complications in the pin group. Three (12%) wrists fixed with pins moved from the immediate postoperative position to a position of relative volar flexion, while radiographs showed no changes in wrist position in the plate group. With both methods, successful arthrodesis stabilized the wrist in a high percentage of patients. Plate fixation offers an excellent alternative method for arthrodesis of the rheumatoid wrist.

Operative treatment with radial shortening in Kienböck's disease.

Eighty-eight patients underwent radial shortening for Kienböck's disease. Prerequisites for surgery were radiographic studies positive for Kienböck's disease without evidence of radiocarpal arthritis and wrist pain unrelieved by conservative management. Thirty-nine patients were evaluated by subjective questionnaire at a mean postoperative follow-up of 86 months (range: 24-188 months). Following surgery, a significant decrease was noted in pain severity, frequency, and duration. Functional status improved postoperatively, with the most significant gains noted in the following activities: opening jars, opening car doors, carrying bags, and shoveling. Only 3 of 34 patients employed outside the home were unable to return to their original occupations due to their wrist problems. Seventy-six patients were evaluated by physical examination at a mean postoperative follow-up of 31 months (range: 3-87 months). Objective evaluation by physical examination revealed a significant improvement in wrist motion and grip strength. Seventy-seven patients underwent radiographic evaluation at a mean postoperative follow-up of 31 months (range: 3-180 months). A significant progression in Lichtman stage of Kienböck's disease was noted despite the favorable subjective findings and high satisfaction ratings. Thirty-six of 39 patients stated they would undergo the surgery again. The long-term data demonstrate radial shortening in patients with stage II-IIIA Kienböck's disease provides substantial improvement over preoperative status.

Treatment of chronic post-traumatic dorsal subluxation of the distal ulna by hemiresection-interposition arthroplasty.

Twenty-four patients were evaluated for complaints of pain in the area of the distal radioulnar joint, decreased forearm rotation, and weakness of grip. All patients had a history of trauma to the involved wrist an average of 40 months prior to presentation. Six patients had undergone previous surgery that was unsuccessful. Twenty-three patients were available for follow-up evaluation at an average of 36 months following hemiresection-interposition arthroplasty. At that time, results were excellent in 13 patients, good in 4 patients, fair in 3, and poor in 3. Two patients developed symptoms of styloidcarpal abutment (poor results), one of whom was upgraded to an excellent result after undergoing a shortening osteotomy of the ulna.

Symptomatic congenital coalition of the pisiform and hamate.

Recent reports have shown that carpal coalition, previously regarded as an asymptomatic congenital anomaly, may be an unusual occult cause of wrist pain. Two cases are presented as the first reported examples of congenital piso-hamate fusion creating symptoms due to associated arthritis or occult fracture.

Intratendinous ruptures of the flexor digitorum profundus tendon of the small finger.

Ten patients had spontaneous ruptures of the flexor digitorum profundus tendon involving the small finger. All ruptures occurred at work with the hand engaged in resisted flexion. Seven patients were treated by surgical means, four patients by direct repair, two by tendon transfer, and one by tendon graft. The ruptures were intratendinous occurring just distal to the A2 pulley in two patients, in the palm in four, and in the carpal canal in one. A pathologic condition to explain the tendon ruptures was not found on gross inspection or subsequent histologic examination. The seven patients treated by surgical means achieved satisfactory results. Follow-up averaged 52 months. Three patients did not have surgical repair and they have been followed-up for an average of 16 months. The results of direct repair within 1 week of rupture were superior to the results of late reconstruction.

Fibrous hamartoma of the wrist in infancy.

Fibrous hamartoma of infancy (FHI) is a rare, self-limiting, benign tumor that occurs in the early years of life. The vast majority of reported cases occur in the proximal upper extremity and torso. A case of FHI that occurred in the wrist of a 9-month-old girl is presented. Diagnostic features of FHI are discussed and emphasized. Surgical treatment is highly successful and is the method of choice.

Erosion of the triquetrum and pisiform bones caused by a foreign body granuloma.

A 16-year-old boy had pain and swelling in the left wrist 6 months after he had fallen on a twig. Erosion of the triquetrum and pisiform was seen on x-ray films. A granulomatous process was identified at operation. Despite numerous cultures and special stains, no organisms were identified. Wood debris was seen under high-power magnification. A wooden foreign body may cause bone and joint destruction through a granulomatous process. In this case, surgical debridement and excision stopped the destructive process.

Open complex metacarpophalangeal joint dislocation. Two cases: index finger and long finger.

Two patients with open complex dislocation of a metacarpophalangeal joint were treated by cleansing of the wound, open reduction, primary wound closure, and early motion. One dislocation occurred in the index finger, the other in the long finger which is only the second such case to be described. Antibiotics were given before and continued for 5 days after operation. There were no infections, and both patients regained an excellent range of motion without pain.

An exercise-induced compartment syndrome of the dorsal forearm--a case report.

A 46-year-old male patient experienced extreme pain in the dorsal forearm after strenuous work. He had the classical physical findings of compartment syndrome and elevation of compartment pressure of 45 mm by direct measurement. A decompressive fasciotomy of the dorsal musculature provided total relief of pain, and subsequently full recovery of all function occurred.