Faculty Bibliography

PURPOSE: Steroid injections are commonly performed by hand surgeons for relief of symptoms associated with carpal tunnel syndrome. The purpose of this study is to examine the relationship of the needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch, using 2 injection techniques. METHODS: Simulated carpal tunnel injections were performed on 15 cadaveric arms using 2 methods. The first injection used a widely accepted approach in which the needle is inserted at the wrist crease, just ulnar to the palmaris longus, and directed at a 30 degrees angle to the horizontal. In the second method, the needle is positioned just ulnar to the palpable ulnar border of flexor carpi radialis and angled 30 degrees to the horizontal. Specimens were dissected using an open carpal tunnel release. Calipers measured the distance from each needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch. RESULTS: Using the first injection method, the needle pierced the median nerve in 4 specimens, and its mean distance from the nerve measured 1.34 mm +/- 1.83 mm. With the second injection method, the median nerve was pierced in 1 specimen, and the needle averaged a distance of 4.79 mm +/- 3.96 mm from the nerve. In the first approach, the needle averaged 9.47 mm +/- 4.11 mm from the palmar cutaneous branch, compared to 1.74 mm +/- 1.59 mm with the second technique. CONCLUSIONS: Physicians must exercise caution when performing carpal tunnel injections to avoid intraneural injection. The needle was a statistically significant shorter distance to the median nerve with the traditional injection method; however, the alterative method risks injury to the palmar cutaneous branch of the median nerve.

Arthritis of the basal joint of the thumb is a condition that is becoming even more common as longevity increases and more people have active lifestyles in later life. The role of new hyaluronase-based injectable agents is evolving. A number of surgical procedures are effective in treating early-stage arthritis; the commonly performed trapezium resection and ligament reconstruction procedures have been modified by using limited-incision approaches, arthroscopic assistance, and bioengineered materials, as well as metacarpal repositioning osteotomy.

PURPOSE: The purpose of this study was to review the long-term outcomes of patients with distal radius fractures treated with closed reduction and percutaneous pinning. METHODS: We retrospectively reviewed 54 patients with 55 AO type A2, A3, C1, or C2 distal radius fractures treated with closed reduction and percutaneous pinning. The average age of the patients was 57 years. All patients returned for follow-up examination at an average of 59 months, with a minimum of 22 months. Measurements included active range of motion, grip strength, pain assessment, Disabilities of the Arm, Shoulder, and Hand scores, and final radiographic assessment. The paired t-test was used to determine significant differences. RESULTS: All fractures healed within 6 weeks. Active range of motion and grip strength of the injured wrist were statistically equal to those of the uninjured wrist for each of the parameters except wrist flexion and forearm supination. However, the difference in wrist flexion was 5 degrees and the difference in supination was 4 degrees , both of which are of little clinical importance. Eighty-five percent of patients were pain free. Radiographic parameters comparing the immediate postoperative view with the views taken at final follow-up showed no significant differences. One patient required reoperation for loss of reduction after a fall in the preoperative period, and 3 others had minor complications. CONCLUSIONS: Patients treated with closed reduction and percutaneous pinning for distal radius fractures had excellent range of motion, normal Disabilities of the Arm, Shoulder, and Hand scores, and no significant differences in the radiographic parameters between fracture fixation and fracture healing. Complications were few. Pinning is an efficacious, low-cost treatment option for 2- and 3-part distal radius fractures with excellent long-term results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

This study compared patients with basal joint arthritis who underwent either ligament reconstruction tendon interposition (LRTI) or trapeziometacarpal interposition arthroplasty (TMIA). Twenty-two consecutive LRTI and 22 TMIA procedures were compared. Arthritis was graded using the staging system of Eaton. In the LRTI group, 1 patient (4.5%) had stage II, 3 patients (13.6%) had stage III, and 14 patients (15 LRTI procedures; 68.1%) had stage IV disease; 3 patients had previous silicone implants (13.6%). In the TMIA group, 3 patients (13.6%) had stage II and 19 patients (86.4%) had stage III disease. Mean age was 62.5 years in LRTI patients and 54.7 years in TMIA patients (P=.005). Mean follow-up was 48 months for both groups. Thumb shortening was determined using preoperative lateral and follow-up pinch lateral radiographs. Functional outcomes and patient satisfaction were analyzed. Pinch strength averaged 8.1 lb for LRTI and 12.6 lbs for TMIA patients; this difference was significant (P<.002). Patients in both groups had high overall satisfaction rates, with scores averaging 8.5 for LRTI patients and 9.2 for TMIA patients. Thumb metacarpal proximal migration was 20.5% in the LRTI group, and 6.5% in the TMIA group; this difference was significant (P=.0006). There was no statistically significant linear correlation between proximal migration and pinch strength (R=0.32, P=.13). Five TMIA patients required revision to LRTI. Patients in both groups reported high satisfaction. Pinch strength was greater in TMIA patients, and proximal migration of the thumb metacarpal was greater in LRTI patients. There was no correlation between proximal metacarpal migration and pinch strength. Increased pinch strength with TMIA may not be sufficiently advantageous to outweigh the risk for revision surgery.

The neurovascular and muscular anatomy about the humerus precludes the use of a truly "safe" fully extensile approach. Working around a spiraling radial nerve at the posterior midshaft requires either a transmuscular dissection or a triceps-avoiding paramuscular technique. To gain maximal exposure, the radial nerve must be mobilized at the spiral groove. For exposure of only the proximal humeral shaft, many surgeons prefer the anterolateral approach because it uses the internervous plane between the axillary and deltoid nerves proximally and the radial and musculocutaneous nerves distally. Proximally, the deltopectoral approach to the shoulder continues to be the most widely used. However, the lateral deltoid-splitting approach is a viable, less invasive approach for both rotator cuff repair and fixation of valgus-impacted proximal humeral fractures. Distally, intra-articular exposure is dependent on triceps mobilization, either by olecranon osteotomy or triceps release; this exposure can be coupled with either a triceps-splitting or a paratricipital approach for proximal extension.

Volar ligament reconstruction is an effective technique for treating symptomatic laxity of the CMC joint of the thumb. The laxity may bea manifestation of generalized ligament laxity,post-traumatic, or metabolic (Ehler-Danlos). There construction reduces the shear forces on the joint that contribute to the development and persistence of inflammation. Although there have been only a few reports of the results of volar ligament reconstruction, the use of the procedure to treat Stage I and Stage II disease gives good to excellent results consistently. More advanced stages of disease are best treated by trapeziectomy, with or without ligament reconstruction

PURPOSE: Acute sagittal band injuries at the metacarpophalangeal (MCP) joint resulting in subluxation or dislocation of the extensor tendons may cause pain and swelling at the MCP joint and limit active extension of the MCP joint. These injuries often are treated with surgical repair or reconstruction. This article outlines a nonsurgical treatment protocol that uses a customized splint for acute, nonrheumatoid extensor tendon dislocations caused by injury to the sagittal bands. METHODS: We retrospectively reviewed 10 patients with 11 acute sagittal band injuries who were treated with a splint of thermally molded plastic that differentially holds the injured MCP joint in 25 degrees to 35 degrees of hyperextension relative to the adjacent MCP joints. All the sagittal band ruptures resulted in complete dislocation of the extensor digitorum communis (EDC) tendon-Rayan and Murray type III injuries. Active proximal interphalangeal and distal interphalangeal motion was begun immediately at the time of initial splinting. The average follow-up period was 14 months. RESULTS: At the time of final evaluation all patients had full range of motion in flexion and extension. Eight patients had no pain and 3 had moderate pain. Four patients (5 digits) had no extensor tendon subluxations and 3 had barely discernable subluxations. Three patients had moderate subluxation of the EDC tendon and their treatments were considered failures. One of these patients had subsequent sagittal band reconstruction. CONCLUSIONS: Our results show acute sagittal band injuries in nonrheumatoid patients resulting in dislocation of the EDC tendon can be managed nonsurgically in many patients with a customized splint called the sagittal band bridge. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV

PURPOSE: Radial collateral ligament (RCL) injuries of the thumb metacarpophalangeal (MCP) joint are much less common than ulnar collateral ligament injuries. Cast or splint immobilization is recommended for treating grade I and grade II tears; however, there is no consensus for treating grade III (complete) tears of the RCL. The purpose of this study was to assess the results of repair of acute grade III tears of the RCL and evaluate the efficacy of late reconstruction for chronic instability. METHODS: From 1986 to 2001 there were 26 patients (16 in the repair group, 10 in the reconstruction group) who were reviewed retrospectively and examined clinically after either repair or reconstruction of the RCL of the thumb. The repair group had surgery at a mean of 2.5 weeks after injury and was evaluated at a mean follow-up time of 4.6 years. The reconstruction group had surgery at a mean of 6.8 months after injury and was evaluated at a mean follow-up time of 5.0 years. RESULTS: At an average follow-up of 59 months, there were no statistically significant differences in MCP or interphalangeal joint motion, grip or pinch strength, or MCP joint stability between the 2 groups. Based on a newly developed grading system there were 12 excellent and 3 good results in the repair group and 8 excellent and 2 good results in the reconstruction group. Overall satisfaction was excellent for both groups. CONCLUSIONS: We recommend the repair of acute grade III RCL injuries and reconstruction of chronic grade III RCL tears of the thumb MCP joint to prevent the development of a painful unstable thumb and possibly to prevent the development of MCP joint arthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.