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The Essex-Lopresti lesion, or radioulnar longitudinal dissociation, results from an axial load to the forearm with injury to the radial head and disruption of the interosseous membrane and the distal radioulnar joint. Unfortunately, an appreciation of the true extent of injury is not always realized in the acute setting, and patients present later with persistent or new reports of forearm discomfort and wrist and elbow pain. Reconstruction of the central band of the interosseous membrane with a bone-patellar tendon-bone graft is useful in the chronic setting and is described.

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.

1. Kang N, Pratt A, Burr N. Miniplate fixation for avulsion injuries of the flexor digitorum profundus insertion. J Hand Surg Br. 2003;28(4):363e368. 2. Bertelli JA, SantosMA, Kechele PR, Rost JR, Tacca CP. Flexor tendon grafting using a plantaris tendon with a fragment of attached bone for fixation to the distal phalanx: a preliminary cohort study. J Hand Surg Am. 2007;32(10):1543e1548. 3. Pulvertaft RG. Tendon grafting for the isolated injury of flexor digitorum profundus. Bull Hosp Jt Dis Orthop Inst. 1984;44(2):424e434. 4. Atik B, Tan O, Dogan A, et al. A new method in tendon repair: angular technique of interlocking (ATIK). Ann Plast Surg. 2008;60(3):251e253. 5. Tanaka T, Amadio PC, Zhao C, Zobitz ME, An KN. Gliding resistance versus work of flexionetwo methods to assess flexor tendon repair. J Orthop Res. 2003;21(5): 813e818.

Peripheral triangular fibrocartilage complex (TFCC) tears are amenable to repair. Limitations of current repair techniques include prolonged recovery and button or knot intolerance. We present a novel technique of an all-inside repair using existing technology (FasT-Fix; Smith & Nephew Endoscopy, Andover, MA) to circumvent these complications. This technique is faster, easily performed, safe, and potentially stronger than current repairs. Earlier motion and rehabilitation are instituted after this repair. The tear is debrided to stimulate angiogenesis. The FasT-Fix is inserted through the 3-4 portal with the arthroscope in the 6R portal. The first poly-L-lactic acid block is deposited peripheral to the tear. Upon penetration of the wrist capsule, a distinct decrease in resistance is felt. The introducer is withdrawn, depositing the block outside the capsule. The trigger on the introducer advances the second block into the deployment position. It is advanced and deposited central to the tear, forming a vertical mattress configuration. The introducer is removed, leaving the pre-tied suture. The knot is tightened and cut by use of the knot pusher/cutter. Multiple implants may be inserted to complete the repair. Postoperative care involves a sugartong splint for 2 weeks followed by a short arm cast for 4 weeks. Range of motion is begun thereafter with strengthening started at 10 weeks.

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.

Ulnar shortening osteotomy is a widely used procedure for a number of pathologic conditions. However, there is little biomechanical data on its effect on the surrounding soft tissue structures. Therefore, the objective of this study was to determine the effects of progressive ulnar shortening on the distal radioulnar joint and the proximal carpal bones.The kinematics and strain between the ulnar styloid, lunate, and triquetrum were evaluated with varying supination and pronation forces. Six fresh-frozen cadaveric upper extremity specimens were tested after progressive ulnar shortening using a custom jig. Biomechanical measurements including strain and translation were made by evaluating the change in position of the digitizing markers on the carpal bones, radius and ulna.There were significant changes in marker positions with respect to intact specimens for each amount of shortening at the ulnar styloid (P0.001), the lunate (P0.001), and triquetrum (P0.001). With progressive ulnar shortening, the strain data demonstrated that there was no significant change in lunato-triquetral strain, but demonstrated a significant increase in both ulno-triquetral and ulno-lunato strain (P0.04).Progressive ulnar shortening increases ulno-triquetral and ulno-lunato strains with an ensuing reduction in motion between the carpal bones.

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.

A kinematic analysis of a progressive, ulnar-sided wrist injury was performed using a cadaver model to study the static and dynamic stabilizers of the distal radioulnar joint with a 3-dimensional motion tracking system. Anatomically based loads were applied to achieve pronation and supination and then the specimens were evaluated after serial transection of the triangular fibrocartilage, the extensor carpi ulnaris sheath, and the ulnocarpal ligaments. Statistically significant increases in translation of the radius relative to the ulna occurred with sectioning of both the triangular fibrocartilage proper and the extensor carpi ulnaris tendon sheath. No significant change in position of the forearm could be appreciated with subsequent sectioning of the ulnocarpal ligaments. Our observations support the idea that the ulnocarpal ligaments do not need to be surgically reconstructed when there are serious injuries to the triangular fibrocartilage complex.

Flexor tendon injuries in children are unique injuries because of the difficulty in diagnosis, poor cooperation of the patient, and the small size of the structures. A high index of suspicion for a flexor tendon laceration in the injured digit of a child must exist, because 25% of these injuries are initially missed. Primary repair should be performed for all ages, in all zones, and for all tendons within 4 weeks of the injury. The repair technique is similar to that of an adult, but the postoperative program must be tailored to the level of cooperation of the patient and parent. Tenolysis and tendon grafting is reserved for children older than 6 years who can actively participate in the treatment program.

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.

Rapidly advancing techniques in arthroscopy and arthroscopic equipment are enabling surgeons to diagnose and treat conditions once thought amenable only to open treatment. Just as knee arthroscopy was initially thought to be a triumph of technology over reason, so has been the criticism of arthroscopy of the thumb carpometacarpal (CMC) joint. Several reports of the results of arthroscopic treatment of various afflictions of the thumb CMC joint are promising.1–3 It is becoming increasingly apparent that the technique of CMC joint arthroscopy is not only reliable, but also may enable the surgeon to diagnose and treat conditions that have failed conservative modalities but do not meet the indications for more aggressive open procedures.

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.

This study examines the real-time intracellular calcium changes of palmar fascia from normal and Dupuytren's diseased fibroblasts in response to shear stress. The real-time cytosolic calcium changes were measured using fluorescence microscopy image processing. The preconfluent primary cultured cells were exposed to 1 minute of flow at 25 dyne/cm2 after a 2-minute baseline of no flow. Additionally, the cells were exposed to an influx of Hank's buffered saline solution with 2% newborn bovine serum to examine the response to serum-born (chemical) agonists. Cytosolic calcium changes were measured as the percentage change over the 2-minute baseline of the mean [Ca2+]i peak. The mean change of the peak [Ca2+]i response of the normal palmar fascia was significantly greater than that of the cells from the Dupuytren's nodular and perinodular tissue. The response to the chemical agonist showed a robust but not statistically different response between the 3 cell types. Our work supports the hypothesis that palmar fascia responds to mechanical stress, specifically laminar fluid flow. These findings may help to explain that an underlying abnormality in the cells of the palmar fascia may be expressed by exposure to laminar fluid flow, a physical signal, rather than a chemical agonist.

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.

SUMMARY Arthrography of the shoulder is an important and accepted technique in the evaluation of shoulder pain. The radiographic findings can often be directly translated into treatment considerations. The role of wrist arthrography is controversial. The radiographic findings are less specific and therefore require more individual interpretation. In our experience, the wrist arthrogram represents a useful adjunctive procedure in the evaluation of unexplained wrist pain.

The use of a prosthetic nerve graft, composed of a resorbable polyorthoester tube, as an alternative to free autogenous nerve grafting for the treatment of a gap in a peripheral nerve was studied, with a cat sciatic nerve as the model. The results demonstrate that regeneration will occur through a resorbable tube spanning a 1.5 cm gap and reinnervate end organ muscle. In those muscles showing evidence of reinnervation, nerve regeneration through the tubes as assayed by electrophysiologic examination demonstrated no difference compared with autogenous nerve grafts, with the exception that the initial rate of regeneration was delayed by 4 to 6 weeks.