Faculty Bibliography

Seventeen consecutive patients with acute unstable proximal pole scaphoid fractures were managed over the past 5 years with open reduction and internal fixation. Four fractures were displaced, with greater than 1 mm of fragment offset and intercarpal malalignment. The operative technique consisted of a dorsal approach to the scaphoid, radius bone grafting, and freehand retrograde Herbert compression screw fixation. The patients were evaluated at an average of 37 months (range, 12-63 months) after surgery. All fractures healed within 13 weeks (average, 10 weeks). Functional wrist range of motion and grip strength were achieved in all patients. No patients developed osteonecrosis or radioscaphoid arthritis. Open reduction and internal fixation rather than primary casting is a better means of reducing the complications of delayed union, nonunion, and irreparable osteonecrosis that often occur after acute proximal pole scaphoid fracture treated with cast immobilization

The new millennium represents a time for expanding our present knowledge of the treatment of distal radius fractures, based on the foundation of information that has been gathered over the past century. Treatment-oriented classifications have replaced the prior generalization applied to all 'Colles fractures' and have directed preoperative planning. Newer external fixation frames, improved surgical technique, and superior instrumentation allow for safer reproducible ligamentotaxis. These current concepts of treatment along with a comprehensive therapy plan have provided the basis for enhanced recovery from these challenging injuries

The primary prerequisites for optimal management of the athlete's fractured wrist are prompt diagnosis, anatomic and stable reduction, effective immobilization until healing is thorough, and comprehensive rehabilitation of the injured parts. Fulfillment of these fundamental criteria consistently leads to a highly favorable outcome with minimal risk of re-injury. In contrast, a compromise of these principles, especially for the sake of a speedy return to sports, invariably results in suboptimal recovery and, not infrequently, a permanent loss of skills. The exceptions to the cardinal rule that successful treatment of wrist fractures requires precise restoration of anatomic relationships are specific: displaced hamate hook fractures, displaced trapezial ridge fractures, and comminuted pisiform fractures. In such instances, successful union essentially is precluded, and early excision of the displaced fragments is the logical means of facilitating an uncomplicated recovery. For the more complex fractures requiring stabilization, continual refinements in methods of fixation are considerably diminishing fracture morbidity. The availability of small screws that provide rigid fixation of the carpus is, with increasing consistency, promoting accelerated union and rapid rehabilitation. Well-conceived combinations of low-profile, mechanically efficient external fixators and precisely used Kirschner wires achieve highly secure fracture stability for the distal radius that similarly enhances recovery with a minimum of complications. Improvements in both design and application of internal and external fixation techniques undoubtedly constitute a major advance in the management of wrist fractures among athletes. For some athletes, the return to competition can be safely expedited by the use of custom-fit protective gloves, splints, or casts. For most, however, the treatment regimen usually entails a minimum of 3 to 4 months. Although the healing and rehabilitation process is often lengthy and may seem costly, particularly in terms of time lost from competition, seldom do athletes regret the investment once they return to their highly skillful activities unencumbered by wrist impairment. Never does the sports medicine physician regret compliance with the principles of optimal care

A complete understand of the anatomy of the ulnar aspect of the wrist and the potential pathologies that may afflict it is the key to making an accurate diagnosis, ordering appropriate ancillary studies, and providing comprehensive patient management for problems in the region. This article focuses on the clinical examination of the skeletal, articular, and soft-tissue components about the distal ulna. Differentiation of distal ulnar maladies from more proximal conditions producing ulnar wrist symptoms is also reviewed

Upper extremity injuries are commonly seen in the sport of in-line skating. The use of protective equipment, including wrist splints, has been advocated as a means to decrease both the incidence and severity of upper extremity injuries in this sport. We report on four cases of open forearm fractures in the in-line skaters that occurred adjacent to the proximal border of the wrist splints. The unusual nature of these injuries and the location of the fractures in relation to the location of the splints suggest that the two may be mechanistically related. The splint and distal forearm may act as a single unit to convert the impact from the level of the wrist to a torque moment, with the fulcrum located at the proximal border of the splint. The energy from the fall is then dissipated by the fracturing of the forearm bones at this level. These cases suggest that the use of wrist splints may be associated with their own specific set of injury patterns.

Controversy persists over the use of the flexor carpi ulnaris for transfer to the extensor digitorum communis in the treatment of radial nerve palsy. Six patients with complete, irreparable radial nerve palsies were treated in part with the flexor carpi ulnaris to extensor digitorum communis tendon transfer (standard transfers: pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, and palmaris longus to the rerouted extensor pollicis longus) and were functionally tested for long-term results. The average follow-up time was 8 years (range, 3-15). A control group was comprised of 10 volunteers of similar demographics. This study evaluates the long-term functional recovery in three categories: range of motion, dynamic power of wrist motion, and functional ability as determined by work simulation techniques. The activities simulated were swinging a hammer, sawing wood, tightening screws, and using pliers. A functional range of motion was maintained in all patients, and the power of wrist motion was sufficient to perform all activities of daily living. The work simulation testing revealed no significant difference between the tendon transfer patients and control group with respect to hand dominance and normal variance. All patients were able to perform the simulated work with the same variance in power as the control group. Despite the obvious anatomic loss, wrist function is not significantly impaired after flexor carpi ulnaris tendon transfer for radial nerve palsy

The rapidly expanding microsurgical knowledge and technology along with a growing experience in replantation has led the way to new concepts of management that have become essential in the progressive treatment for these complex injuries. Appropriate patient selection, proper modes of limb transportation, injury assessment, surgical technique, and postoperative care are all key components to successful recovery and restoration of function. As the ability to restore vascular flow to amputated digits, hands, and limbs has advanced, critical evaluation of the potential extent of recovery in comparison to amputation revision is imperative. This article discusses the current ideas of the perioperative treatment for replantation with specific attention directed towards these evolving issues

MR imaging is emerging as an invaluable tool in the diagnosis of hand and wrist disorders. It is extremely accurate in the diagnosis of stage 1 Kienbock's disease when plain radiographs are equivocal and in evaluating bone and soft-tissue tumors of the hand and wrist. MR imaging is replacing arthrography as the imaging modality of choice for disruptions of the TFCC. With refined technology and improved resolution, abnormalities involving the intercarpal ligaments ultimately will be able to be detected with a high degree of precision

Ligamentotaxis employing either pins and plaster or external fixators, frequently in conjunction with supplemental Kirschner wire internal fixation, has proved to be a reliable means of maintaining an accurate reduction of unstable articular fractures of the distal radius. Critical preoperative evaluation and surgical restoration of articular congruity along with attention to key technical details have resulted in a reproducible successful recovery. In our experience, the advantages of the pins and plaster technique are its relatively simple methodology, its comparatively low cost, and its high level of patient acceptance. The distinctive advantages of the external fixator are its superior mechanical efficiency, its capacity for fracture adjustment during the healing period, and the fact that it ensures unimpeded access to wounds. Nonetheless, regardless of the specific method chosen, this study clearly supports the contention that precision in patient selection and pin placement are the prerequisites for successful ligamentotaxis in the management of distal radius fractures

Heightened awareness of the pathologic conditions resulting in acute vascular trauma will govern the success of management. A thorough examination with appropriate vascular studies followed by meticulous surgical intervention and a carefully monitored postoperative course avoids the associated complications of these challenging injuries