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Ganglion cysts about the wrist are a common pathology that presents to hand surgeons. The majority is dorsal, originating from the scapholunate ligament, but volar and occult ganglions are also common and symptomatic. Treatment options for these masses include observation, aspiration, or surgical excision. Historically, open surgical excision has been the gold standard of treatment; however, arthroscopic excision is becoming more favorable due to its minimally invasive nature and decreased postoperative recurrence rates. Concerns regarding limited visualization and volar ganglion excision exist; however, newer surgical techniques and data continue to support the arthroscopic technique. This chapter contains a video.

Aims The aims of this study were to compare the mid-term outcomes of patients with late-stage arthritis of the wrist treated with proximal row carpectomy (PRC) and dorsal capsular interposition (DCI) arthroplasty with a matched cohort treated with routine PRC alone. Patients and Methods A total of 25 arthritic wrists (24 patients) with pre-existing degenerative changes of the proximal capitate and/or the lunate fossa of the radius were treated with PRC + DCI over a ten-year period. This group of patients were matched 1:2 with a group of 50 wrists (48 patients) without degenerative changes in the capitate or lunate fossa that were treated with a routine PRC alone during the same period. The mean age of the patients at the time of surgery was 56.8 years (25 to 81), and the demographics and baseline range of movement of the wrist, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were similar in both groups. Results At a mean follow-up of 5.9 years (1.8 to 11.8), significant improvements in mean grip strength, the flexion-extension arc of movement of the wrist, QuickDASH, and PRWE scores were seen in both groups. There was no diifference between the groups for any of the outcomes. One patient in the PRC + DCI group required additional surgery for a deep infection, while two in the PRC group had complications (one wound dehiscence requiring revision closure, one transient radial sensory neuritis). One patient in each group required total arthrodesis of the wrist for progressive degenerative radiocarpal changes. A total of 70 patients (93%) were satisfied with the outcomes. Conclusion PRC with DCI is an effective form of treatment for late-stage arthritis of the wrist involving the capitolunate joint, with mid-term outcomes that are similar to those in patients without degenerative changes affecting the capitate or lunate fossa who are treated with a routine PRC alone. Cite this article: Bone Joint J 2018;100-B:197–204.

Thoracic outlet syndrome is a controversial entity. Diagnosis requires a thorough examination and is primarily clinical. Three main presentations exist: Neurogenic, arterial, and venous. Most cases can be managed non-operatively. Surgical decompression of the thoracic outlet space can be helpful in recalcitrant cases.

Post-traumatic radioulnar synostosis is a rare complication after forearm or elbow injury that can result in loss of motion and significant disability. Risk factors include aspects of the initial trauma and of the surgical treatment of that trauma. Surgical intervention for synostosis is the standard of care and is determined based on the location of the bony bridge. Surgical timing is recommended between 6 months and 2 years with recent advocacy for the 6- to 12-month period after radiographs demonstrate bony maturation but early enough to prevent further stiffness and contractures. For most types of synostosis, surgical resection with interposition graft is recommended. The types of materials used include synthetic, allograft, and vascularized and non-vascularized materials, but currently there is no consensus on which is the most preferable. Adjuvant therapy is not considered necessary for all cases but can be beneficial in patients with high risk factors such as recurrence or traumatic brain injury. Postoperative rehabilitation should be performed early to maintain range of motion.

Purpose To survey emergency medicine (EM) residency and hand surgery fellowship program directors (PDs) to identify consensus in their perceptions of appropriate emergency care of upper extremity emergencies. Methods We created a framework to group common upper extremity emergency diagnoses and surveyed PDs to evaluate the training background—EM, general orthopedic or plastic surgery, or hand fellowship—most appropriate to provide acute, point-of-care management for each of these diagnostic groupings. Responses were pooled and consensus was established with greater than 75% agreement between groups. Results We received 79 responses from hand fellowship PDs (90% response rate) and 151 responses from EM PDs (49% response rate). We identified consensus for the training background that PDs in both specialties felt was appropriate to care for 17 of 21 diagnostic groupings in the framework. Conclusions There was a high level of consensus between EM and hand surgery PDs regarding diagnoses that acutely require training in hand surgery versus those that can be managed by an EM physician. Our diagnostic framework may help reduce unnecessary hand surgery consultation and may help to identify patients who do not require more specialized acute care and thus decrease unnecessary transfers. Type of study/level of evidence Economic and Decision Analyses IV.

Background: Recalcitrant lateral epicondylitis (LE) is a common debilitating condition, with numerous treatment options of varying success. An injection of platelet-rich plasma (PRP) has been shown to improve LE, although it is unclear whether the method of needling used in conjunction with a PRP injection is of clinical importance. Purpose: To determine whether percutaneous needle tenotomy is superior to percutaneous needle fenestration when each is combined with a PRP injection for the treatment of recalcitrant LE. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 93 patients with recalcitrant LE were treated with a PRP injection and percutaneous needle fenestration (n = 45) or percutaneous needle tenotomy (n = 48) over a 5-year study interval. Preoperative patient data, including visual analog scale for pain (VAS-P), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Tennis Elbow Evaluation (PRTEE) scores and grip strength, were obtained from a chart review and compared with postoperative values obtained prospectively. Secondary outcomes included the incidence of complications, need for additional interventions, return to work, and patient satisfaction. Results: At a mean follow-up of 40 months, significant improvements in VAS-P (mean, –6.1; 95% CI, –6.8 to –5.5; P < .0001), QuickDASH (mean, –46; 95% CI, –52 to –40; P < .0001), and PRTEE (mean, –57; 95% CI, –64 to –50; P < .0001) scores and grip strength (mean, +6.1 kg; 95% CI, 4.9 to 7.3; P < .0001) were observed across the entire study cohort, with no significant differences noted between the fenestration and tenotomy groups. Nine of 45 patients (22%) underwent additional procedures to treat recurrent symptoms in the fenestration group compared with 5 of 48 patients (10%) in the tenotomy group ( P = .05). No complications occurred in any patients, and no patients expressed dissatisfaction with their treatment course. Conclusion: A PRP injection with concomitant percutaneous needling is an effective treatment for recalcitrant LE, with sustained improvements in pain, strength, and function demonstrated at a mean follow-up of longer than 3 years. Although the method of concomitant needling does not appear to have a significant effect on treatment outcomes, more aggressive needle tenotomy is less likely to require conversion to open tenotomy than needle fenestration in the short term to midterm.

BackgroundThis study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release.MethodsThe method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ).ResultsPatients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months±5.0), while patients in group 2 had a 59.3 % increase (10.0 months±6.9). BCTQ surveys from group 1 ( n=46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9±10.6 months. Group 2 ( n=42) surveys demonstrated averages of 12.88 and 9.10 at 43.1± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision.ConclusionNo significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.

Adult traumatic brachial plexus injury involves injury of the C5-T1 spinal nerves. Common patterns of injury include "upper arm" and "total arm" types. The specific signs of preganglionic avulsion injury infer a poor prognosis for spontaneous recovery and surgery may be needed. Detailed preoperative evaluation is recommended for localization of the lesions. The treatment of upper arm type injury comprises restoration of elbow flexion and shoulder control. Good functional results may be achieved after multiple nerve transfers. The treatment of total arm type includes hand function reconstruction, in addition to shoulder and elbow treatment. Current options for hand function reconstruction include functioning free muscle transfers and nerve transfers.

Trapeziometacarpal osteoarthritis is a common problem, due to the anatomy of the first ray and the forces applied to the trapeziometacarpal joint throughout activities of daily living. Numerous treatment options exist, and continue to be developed, for this problem. The current goal is to eliminate pain and restore function and strength in a timely manner. New advances allow for earlier return to function with minimally invasive techniques. Arthroscopic hemitrapeziectomy combined with interposition arthroplasty and/or suspensionplasty is a treatment option for Stage II and III trapeziometacarpal arthritis that uses a minimally invasive technique and allows for earlier return of function.

The purpose of this study was to determine the outcome of arthroscopic hemitrapeziectomy combined with thermal capsular plication and temporary K-wire fixation in patients with painful thumb basal joint due to either osteoarthritis or posttraumatic arthritis. There were 18 thumbs that were evaluated in this retrospective study of arthroscopic hemitrapeziectomy of the distal trapezium in addition to a pancapsular thermal shrinkage at an average of 7.6-year follow-up. No patient has required further surgery. A subjective improvement in pain, pinch activities, strength, and range of motion (ROM) was noted in all patients, and no patient had further surgery on their thumb. On exam, no patient had a first carpal–metacarpal grind or laxity. Total ROM of the thumb axis decreased by 20%, but all patients could oppose to the fifth finger. Grip strength remained unchanged, key pinch improved from 8 to 11 lbs, and tip pinch improved from 4 to 5 lbs. Radiographs showed a metacarpal subsidence of 1.8 mm (0–4 mm). Four complications were noted: two cases of dorsal radial nerve neuritis, one rupture of the flexor pollicis longus, and one prolonged hematoma. Results demonstrate that arthroscopic hemitrapeziectomy and capsular shrinkage for first carpometacarpal arthritis is an effective technique that provides high patient satisfaction, a functional pain-free thumb, and a reliable rate of return to activity.

In this article we describe the fundamental concepts that were established by Essex-Lopresti over 50 years ago and explore the current concepts in anatomy, biomechanics, diagnosis, and treatment for longitudinal radioulnar dissociation. Moreover, we present encouraging results for treating chronic injuries to the IOM achieved by bone-ligament-bone (BLB) reconstruction using a patellar tendon graft, giving hope for this seemingly unforgiving injury. A treatment algorithm is also provided to aid in the management of acute and chronic longitudinal radioulnar dissociation.

Radiographic interpretation of pediatric elbow trauma presents a daunting task for both the radiologist and treating orthopaedic surgeon. Proper radiographic diagnosis and appropriate intervention requires a thorough understanding and appreciation of developmental anatomy. As the pediatric elbow matures, it transitions from multiple cartilaginous anlagen through a predictable pattern of ossification and fusion. When children sustain trauma to the elbow, they may have a limited capacity to communicate specific complaints and are sometimes difficult to examine reliably. Furthermore, the presence of multiple growth centers, and their variability, makes radiographic evaluation of pediatric elbow injuries particularly challenging. These variables, coupled with the known adverse long-term sequelae of pediatric elbow trauma (painful nonunion, malunion, elbow stiffness, growth disturbance, etc.) highlight the importance of accurate radiographic interpretation, which facilitates appropriate treatment. By using an orderly, systematic approach based on well-defined anatomical relationships and accepted radiographic markers, the radiologist may effectively interpret and communicate pertinent findings to the treating orthopaedic surgeon. Furthermore, using common classification systems may facilitate interdisciplinary communication. Finally, it is crucial that caregivers of children consider the possibility of child abuse in suspect cases.

Dermatofibrosarcoma Protuberans (DFSP) is an extremely rare low-grade sarcoma of fibroblast origin, with an incidence in the Unites States estimated at less than five cases per million persons per year [1, 2]. Though metastasis of DFSP is rare, local recurrence rates as high as 60 % have been reported [1, 2]. This is most likely a result of the tumor’s highly irregular three-dimensional shape with “finger-like” extensions, which allow for extensive involvement of subcutaneous tissue, muscle, fascia, and bone [1, 2]. Majority of local recurrences occur within the first 3 years of resection, with recurrences at greater than 10 years from index resected very rarely reported [3].

The patient was a 39-year-old right-hand-dominant male who presented with right wrist pain for several months. He was playing football and had a fall landing on his outstretched right hand. Previous to this, he had been diagnosed with a right scaphoid fracture 10 years ago also while playing football. This was initially treated with casting and subsequent bone stimulation. This initial fracture had gone on to nonunion and was subsequently treated with Russe bone grafting and K-wire fixation in which the patient was told the fracture healed. He noted that he had been asymptomatic for the previous 9 years after his wrist healed. At our evaluation, the patient was able to localize the pain to the radial aspect of the wrist and described it as a sharp sticking pain. In addition, he noted worsening pain with wrist extension and push-off that limited both his work and leisure activities. He complained of weakness of his hand especially when trying to hold or grip something heavy. He denied any numbness or tingling in his hand or fingers and has not had any treatment other than NSAIDs for pain.

Ganglion cysts are the most common tumor in the wrist. Dorsal carpal ganglion cysts represent 60 to 70% of all ganglion cysts in the hand and wrist. Standard treatment has been limited to observation, rest, immobilization, aspiration with or without injection, and surgical excision. Arthroscopic resection of dorsal carpal ganglion cyst have been done since the late 1980s. It has the advantages of less scarring and stiffness, the ability to inspect the wrist for other pathology and wrist instability. To date, the success of arthroscopic ganglion cyst resection is at least as good (1% recurrence) as current open techniques (0 to 10% recurrence). Risks of the procedure are similar to open techniques. Patient satisfaction with the procedure is high. In the largest reported series, there have been no major complications. This technique, for those who are comfortable with wrist arthroscopy, is effective and safe in treating this common wrist mass. The technique for this procedure is described as well as a brief history of treatment for dorsal carpal ganglion cysts.

Fractures of the distal radius and the scaphoid are common injuries in adults. In recent years, surgical fixation of these types of fractures has increased in response to improved patient outcomes and evolving fixation techniques. Potential soft-tissue, neurovascular, or osseous complications, including tendon injuries, carpal tunnel syndrome, loss of fracture reduction, and osteonecrosis, can increase the time the patient requires immobilization and can lead to poor patient outcomes. Prompt recognition and diagnosis of these complications may improve patient outcomes and satisfaction.

Leri-Weill dyschondrosteosis (LWD) (MIM 127300) is a dominantly inherited skeletal dysplasia characterized phenotypically by Madelung wrist deformity, mesomelia, and short stature. LWD can now be defined genetically by haploinsufficiency of the SHOX (short stature homeobox-containing) gene. We have studied 21 LWD families (43 affected LWD subjects, including 32 females and 11 males, ages 3–56 yr) with confirmed SHOX abnormalities. We investigated the relationship between SHOX mutations, height deficit, and Madelung deformity to determine the contribution of SHOX haploinsufficiency to the LWD and Turner syndrome (TS) phenotypes. Also, we examined the effects of age, gender, and female puberty (estrogen) on the LWD phenotype. SHOX deletions were present in affected individuals from 17 families (81%), and point mutations were detected in 4 families (19%). In the LWD subjects, height deficits ranged from −4.6 to +0.6 sd (mean ± sd = −2.2 ± 1.0). There were no statistically significant effects of age, gender, pubertal status, or parental origin of SHOX mutations on height z-score. The height deficit in LWD is approximately two thirds that of TS. Madelung deformity was present in 74% of LWD children and adults and was more frequent and severe in females than males. The prevalence of the Madelung deformity was higher in the LWD vs. a TS population. The prevalence of increased carrying angle, high arched palate, and scoliosis was similar in the two populations. In conclusion, SHOX deletions or mutations accounted for all of our LWD cases. SHOX haploinsufficiency accounts for most, but not all, of the TS height deficit. The LWD phenotype shows some gender- and age-related differences.

PURPOSE Prior reports on scapholunate ligament (SLL) and lunotriquetral ligament (LTL) tears have evaluated complete tears. As these complete tears have markedly different biomechanical manifestations and surgical considerations than do partial tears, we evaluated the accuracy of MR and the usefulness of secondary MR signs to diagnose partial interosseous ligament tears. METHOD Fifty wrists in 50 patients underwent arthroscopy following 1.5 T MR. Images were evaluated by two independent blinded observers for normal or partially torn SLL and LTL and for three secondary signs potentially seen as mechanical sequelae of tears: osseous offset, arc disruption, or focal osteoarthritis. RESULTS Arthroscopically, there were 16 SLL and 14 LTL partial tears. Accuracy of primary MR signs of partial tears was lower than that described in the literature for complete tears [sensitivity/specificity (kappa) = 0.56/0.56 (0.12)-SLL, 0.31/0.76 (0.13)-LTL]. Secondary signs showed low sensitivity but high specificity, particularly for LTL tears: arc disruption [0.17/0.83 (0.43)-SLL, 0.0/1.00 (1.0)- LTL], focal osteoarthritis [0.32/0.78 (0.18)-SLL, 0.11/0.91 (0.12)-LTL], and focal osseous offset [0.39/0.75 (0.10)-SLL, 0.26/0.93 (0.39)-LTL]. Additionally, there was poor interobserver consistency for both primary and secondary signs. CONCLUSION The sensitivity of morphologic evaluation for diagnosing partial intercarpal ligament tears, particularly those of the LTL, is limited. Secondary signs increase specificity but have low sensitivity, and with the exception of arc disruption, all signs had poor interobserver agreement.

One-bone forearm surgery is generally regarded as one of the last available salvage procedures that could be used to treat patients with longitudinal forearm instability secondary to a congenital, oncologic, or a post-traumatic etiology. We performed this procedure on a 23-year-old patient with longitudinal forearm instability secondary to Hajdu–Cheney syndrome, which is a rare genetic disorder characterized by generalized ligamentous laxity, skeletal dysplasia, acro-osteolysis, and generalized osteoporosis. The patient developed shoulder pain secondary to overuse 28 months following treatment, and was managed conservatively. Eight years after surgery, the patient had not undergone any additional procedures, had no pain, reported a Quick Disabilities of the Arm Shoulder and Hand score of 21, and was completely satisfied with treatment. Although OBF procedure is a radical first-line salvage option, in unique circumstances and appropriate patient selection, it may provide acceptable, durable, and predictable results.

Background Trigger digit is a common pathology encountered by hand surgeons, but there is a lack of evidence-based guidelines. We investigated the treatment preferences of hand surgeons and explored whether geographic location, type of residency training, or clinical experience is associated with differences in practice. Methods An online survey was distributed via email by the American Association for Hand Surgery to 615 members. The survey consisted of 17 questions related to conservative and operative management of trigger digits. Results One hundred thirty-nine unique responses were received (22.6 %). Geographic distribution of respondents encompassed the entire USA and was not associated with variations in practice. Of the respondents, 56.8 % were trained in orthopedic surgery while 37.4 % had plastic surgery training. In regards to duration of practice, 8.6 % were in practice for up to 5 years, 29.5 % for 6–15 years, 33.8 % for 16–25 years, and 28.1 % for more than 25 years. Notably, the great majority of respondents preferred corticosteroid injections for initial treatment. Those who were willing to give three or more injections prior to surgery were more likely to be plastic surgeons in practice for 16 years or more. A large minority of surgeons utilized splinting in their conservative management. Orthopedic surgeons were more likely to perform tenolysis during pulley release and more likely to use monitored anesthesia care. Conclusions Variation exists between the treatment algorithms of hand surgeons when managing a trigger digit. Some of these differences may be attributable to the type of training or the duration of clinical practice.

Malunion of the metacarpal or phalanx can result in significant functional impairment of the hand. Ideally, thissituation is best dealt with by prevention. When faced with a malunion, surgical correction can be a formidable task. However, anatomic alignment can be restored by osteotomy. This paper will explore the techniques of osteotomy, as they apply to a variety of metacarpal and phalangeal malunions. The key to optimal outcome is preoperative planning, meticulous surgical technique, rigid internal fixation and early postoperative range of motion.

This article reviews the history of total wrist arthroplasty as a treatment option for painful, nonfunctional wrists in disease states. Technologic advances in materials, wear properties, and manufacturing now account for increased implant longevity. They may also improve total wrist replacement design, survival, and hence patient function. Also, alternative surgical treatments such as distal radius hemiarthroplasty may serve as a treatment option for patients with higher activity levels and diffuse arthritis. With careful patient selection, soft tissue considerations, and novel implant designs, TWA may become a viable treatment staple for patients with functional wrist disability.

Surgical release of the transverse carpal ligament for the treatment of carpal tunnel syndrome (CTS) is, in general, a very successful procedure. Some patients, however, fail this standard release and have persistent or recurrent symptoms. Such recalcitrance may relate to incomplete release but more often relates to perineural or intraneural fibrosis of the median nerve. While there is no good treatment for intraneural fibrosis, numerous procedures have evolved in an attempt to treat perineural fibrosis which restricts nerve gliding. These include procedures to isolate the nerve from scar as well as procedures to bring neovascularization to the median nerve. This review describes the various surgical treatment options for recalcitrant CTS as well as their reported outcomes.

It is not uncommon for longitudinal forearm instability to be recognized quite late after the injury. Frequently, this injury is not appreciated until there have already been changes at both the wrist (ulnar carpal abutment) and the elbow (radiocapitellar abutment). These late cases frequently require an ulnar shortening osteotomy, as well as radial head prosthesis and/or reconstruction of the interosseous ligament. If continued problems result and there are degenerative changes or chronic pain at the radial capitellar joint, a radiocapitellar prosthesis can be considered. The final treatment for some patients may require creation of a one-bone forearm. This prevents any further longitudinal instability of the forearm; however, it obviously results in loss of forearm rotation. These injuries are best treated early and aggressively, as later reconstructive options will usually result in decreased function of the extremity. This chapter goes through the different reconstructive options that are available to the reoperative surgeon.

There are no records in Greek or Roman literature describing the condition of Dupuytren’s disease. The gesture of legality or truth as seen in Roman statues mirrors the classic contracture seen in Dupuytren’s (Fig. 24.1).

Degenerative joint disease affecting the thumb metacarpophalangeal and interphalangeal joints is a debilitating condition, which can significantly restrict activities of daily living. Conservative measures to address symptoms include oral anti-inflammatory medications, activity modification and splinting, and intraarticular corticosteroid injections. Surgical interventions include arthroscopic synovectomy, arthroplasty, and finally arthrodesis of the affected articulations. Although short-term results from synovectomy and arthroplasty seem promising, long-term data are not yet available. Arthrodesis of the metacarpophalangeal and interphalangeal joints yields a stable yet functional thumb with reliably good pain relief.

As recently as 10 years ago, the thumb carpometacarpal (CMC) joint, or basal joint, was inherently difficult to evaluate intraarticularly. Its curved articular surfaces required an extensive arthrotomy through much of its nearly circumferential stabilizing ligaments. The introduction of a small arthroscope allowed the thumb CMC articulation to be completely visualized without destabilizing the joint.1,2 Diagnostic thumb CMC arthroscopy eventually led to therapeutic arthroscopy, including the treatment of basal thumb arthritis, the most common hand arthrosis. With advancing technology, end-stage and intermediate-stage arthrosis may now be treated by arthroscopically-guided arthroplasty of the thumb basal joint. The development of miniaturized thermocouple probes allowed conditions of joint capsule laxity to be treated by thermal capsular shrinkage. Although early results are promising and the advantages over traditional open procedures are obvious, these techniques are still evolving and the long-term benefits and complications require further study. The purpose of this chapter is to present the current knowledge of arthroscopic treatment for thumb CMC arthrosis and joint hyperlaxity.

Purpose: A large series of patients with Preiser's disease was reviewed to compare 2 potentially different categories of this disorder: complete versus partial vascular impairment of the scaphoid bone as determined by magnetic resonance imaging (MRI). Methods: Nineteen patients with Preiser's disease were identified retrospectively from 2 institutions. Using MRI criteria, 2 disease patterns were identified: diffuse necrosis and/or ischemia of the scaphoid (type 1 disease, 11 cases) and segmental vascular impairment of the scaphoid (type 2 disease, 8 cases). Risk factors for osteonecrosis, treatment methods, and serial radiographs were reviewed in all cases. Sixteen patients were examined for the purpose of this study at an average follow-up of 25 months. Results: MRI signal changes of necrosis and/or ischemia involved 100% of the scaphoid in type 1 cases and on average approximately 42% in type 2 cases (range, 33% to 66%). In type 1 cases, regardless of the treatment used, the scaphoid typically fragmented and collapsed. In type 2 cases, scaphoid architecture was altered minimally after similar treatment methods. A history of wrist trauma was significantly more common in type 2 cases, and the results of treatment were generally better in this group of patients (mean Mayo modified wrist scores, 86 vs 58 points). Conclusions: This study supports the concept of 2 patterns of scaphoid involvement in Preiser's disease. Type 1 cases are characterized by MRI signal changes of necrosis and/or ischemia involving the entire scaphoid bone. Patients in this group have a propensity for scaphoid deterioration. Type 2 cases have MRI signal changes involving only part of the scaphoid. These patients commonly report a history of wrist trauma, show fewer tendencies toward scaphoid fragmentation, and may have a more favorable clinical outcome.

Many factors influence the development of CTS; therefore, nonoperative treatment should not be limited to only one intervention. Nonoperative treatment is most effective in the early stages, prior to irreparable damage to the nerve. Early intervention combined with a comprehensive treatment plan can help improve effectiveness of treatment during this phase. We do not endorse any one particular conservative treatment/program as the solution for CTS, but our purpose is to explore potential options. Further study is needed to determine the most beneficial and cost-effective treatments.

With the development of better and smaller equipment, arthroscopy of the wrist offers the same benefits achievable with arthroscopy of the knee, shoulder, or elbow—not only diagnostic information but also a therapeutic option. Standardized techniques of performing wrist arthroscopy have been developed to evaluate and treat various wrist disorders, such as lesions of the triangular fibrocartilage complex, intra-articular distal radius fractures, and scaphoid fractures. Arthroscopy is now performed in the treatment of dorsal-wrist ganglion cysts and interosseous ligament disruptions, as well as for bone excisions, such as radial styloidectomy, distal ulnar excision (wafer procedure), and proximalrow carpectomy. Compared with open techniques, arthroscopic procedures, such as repair of the triangular fibrocartilage complex, demonstrate better results and improved localization of the injury with a low complication rate. In addition, arthroscopic procedures involve less surgical dissection, less postoperative pain, a shorter recovery time, and an earlier return to work for the patient. J Am Acad Orthop Surg 2001;9:200-209

Ganglion cysts are the most common soft tissue tumors of the hand. They have been reported to arise from virtually every joint and tendon sheath of the hand and wrist. By far the most frequent location is the dorsal wrist, comprising 60% to 70% of all ganglia.1 Despite their prevalence, the etiology of these cysts remains somewhat controversial. The association of these mucinous tumors with underlying joints has led to the predominant theory that they arise as outpouchings or synovial herniations from the joint itself. Contrast-dye injection into ganglia have been inconclusive in showing direct communication with the joint, which has led to the idea of a one-way valve mechanism within the tortuous stalk.2,3 Specifically regarding dorsal ganglions, Angelides and Wallace2 have defined their origin as arising from the scapholunate (SL) ligament.

Between 1975 and 1995, 7 patients were surgically treated for persistent forearm pain following previously unsuccessful attempts of constructing a radioulnar synostosis using interosseous bone grafting with either cross screw or pin fixation. These prior reconstructive procedures were salvage operations to address symptomatic radioulnar instability. The time interval between index operation and revision surgery was a mean of 12.6 months (range, 4–36 months). The postoperative follow-up period averaged 29.7 months (range, 11–61 months). To address these failed radioulnar arthrodeses, plate osteosynthesis and aggressive bone grafting were used in 5 of 7 patients (group 1) (4 with autologous graft and 1 with demineralized bone matrix). Union was achieved in all 5 patients after a single revision operation. Radiographic evidence of solid union was seen at approximately 4 months. In the remaining 2 patients (group 2), revision synostosis procedures were performed; these involved local bone grafting and repeat transverse screw fixation in 1 patient and iliac crest bone grafting alone in the other. One of these 2 patients progressed to union; the other had a persistent symptomatic fibrous union. The 5 patients in group 1 reported symptomatic relief, while the 2 patients in group 2 were dissatisfied. There were no postoperative complications in our series. Based on our findings, we advocate abundant bone grafting and plating for rigid internal fixation in failed radioulnar synostosis procedures.

Purpose To present the outcomes after one-bone forearm (OBF) surgery for chronic posttraumatic forearm and distal radioulnar joint instability. Methods We conducted a retrospective chart review to study patients who underwent OBF surgery because of a traumatic etiology. We collected patient demographics, surgical technique, preoperative and postoperative range of motion, final grip strength, and complications from the medical records. Patients were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, a 0- to 10-point pain scale, and a 0- to 10-point treatment satisfaction scale. Results There were 5 male and 5 female patients, with a mean age of 32 years at the time of OBF surgery (range, 17–44 y). The mean number of procedures before OBF surgery was 3.6 (range, 2–7); 4 patients had undergone a Darrach procedure and 3 patients had undergone a Sauve-Kapandji procedure. The median clinical follow-up duration was 6 years (range, 1–17 y). Wrist and elbow range of motion did not change remarkably before and after surgery. Of 8 primary OBF surgeries, 3 resulted in nonunion. Of 10 patients, 4 experienced painful impingement of the remaining proximal radius on adjacent bone and soft tissue and required a total of 7 procedures after OBF surgery. The median follow-up duration for patient-rated outcomes was 10 years (range, 5–21 y; n = 7). The median Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score was 77, the median pain score was 7, and the median satisfaction score was 7. Conclusions In our experience, complications after OBF surgery are common. Although wrist and elbow range of motion were spared, pain persisted and functional outcomes were poor. One-bone forearm surgery is our last resort for a chronically painful and unstable forearm. Type of study/level of evidence Therapeutic IV.

A prospective study involving eight institutions was performed, incorporating 640 cases of carpal tunnel release using a dual portal endoscopic technique. The original transbursal technique described by Chow was used in 110 cases (17%), and the modified extrabursal technique was used in 530 cases (83%). An overall complication rate of 11% was found in the patients in whom the transbursal technique was used, compared with 2.2% in the patients in whom the extrabursal technique was used. The return-to-work status was followed in 291 cases (199 non-worker's compensation cases and 92 worker's compensation cases). The worker's compensation patients returned to work in an average of 57 days, compared with 22 days for non-worker's compensation patients. This study suggests the extrabursal dual portal endoscopic technique is associated with fewer complications than the transbursal approach, and patients covered by worker's compensation return to work later than non-worker's compensation patients.

27%) in forceful pinch. Poor wrist postures (flexion or extension .45 degrees) occurred most frequently for left wrist during carpet installation (21% of time), (see Figure 2). A small amount of time required poor wrist postures simultaneously with high grip or pinch forces for all materials (3.7%). Conclusion: This analysis showed that floor layers have varying levels of exposure to physically demanding work. Forceful grip was much more common to install wood and ceramic materials while high pinch was common to vinyl installation. Poor wrist postures were more common in the left than right arms. All floor layers must attain good tolerance to perform work tasks with forceful grip and pinch in order to successfully return to work following injury. This investigation examined differences in job demands for one construction trade. These results illustrate the need for interviewing workers to obtain detailed information on work tasks to recognize high levels of physical and functional requirements for different work types. Recognizing workers’ physical job demands can be used to form hand therapy treatment and client education as well as identify areas for ergonomic interventions to prevent future injuries.

Twenty patients underwent proximal row carpectomy and were retrospectively evaluated for pain, motion, grip strength, functional activity, and x-ray changes at a mean follow-up of 3 1/2 years. For nonrheumatoid patients, motion decreased 15% after surgery, mean grip strength improved 22%, and 82% believed their conditions were improved and said they would repeat the procedure. The procedure failed in all three patients with rheumatoid arthritis. Patients with mild preoperative arthritic changes had better results than those with advanced disease.

We report the results of the treatment of multiple ruptures of extensor tendons to the fingers at wrist level in the rheumatoid patient by free tendon grafts. Twenty-three patients averaged 65 degrees of active motion at the metacarpophalangeal joints when seen at an average follow-up of 43 months.

Seventy-one percent (12 out of 17) of the previously treated nonunions united within 12 weeks by a semi-invasive technique of electrical stimulation. The electrodes are stainless steel and Teflon-coated except for the 1 cm bare tip. The power source is a 7.5 volt battery in circuit with resistors and transistors such that a constant continuous current of 20 muamp is applied to each electrode. Three or four cathodes are implanted percutaneously, using local or regional anesthesia with radiographic control, usually an image intensifier. A long-arm cast is used for three weeks and then reduced to a short-arm cast which is used for nine additional weeks. The indication for this technique is failure of previous bone grafting. The contraindications are wrist arthritis and an avascular proximal pole. Patient acceptance of this electrode technique was high and morbidity was less than in those patients treated by iliac bone grafting. The treatment of nonunion of the scaphoid by this semi-invasive electrical stimulation technique is a reasonable alternative to bone grafting and provides a salvage procedure when bone grafting or other therapeutic modalities have failed.