Faculty Bibliography

We describe a hand therapy protocol aimed at unloading the wrist and increasing blood supply to the wrist, specifically to the lunate. The protocol was used in a series of patients with clinical radial wrist pain, dysfunction and changes on wrist imaging studies. The patients were not candidates for surgical treatment. Application of the therapy protocol improved objective and subjective parameters such as pain and motion, and may provide a viable treatment option for patients with lunate overload or early Kienbock's disease that are not candidates for surgery.

Background The most common forms of salvage surgery for wrist arthritis of any stage are four corner fusion and proximal row carpectomy. Younger, high demand patients with early arthritis may not be candidates for this type of salvage surgery. We describe a technique and preliminary case series of a minimal radiocarpal arthroplasty aimed at patients with initial and isolated wrist arthritis (stage 1). This procedure does not preclude any procedure that may become necessary in the future. Patients A series of nineteen male heavy laborers with scapholunate advanced collapse (SLAC grade 1-2) wrist osteoarthritis that felt the wrist arthritis was prohibiting their function enough to warrant surgery, but were unwilling to undergo a salvage procedure, were treated with the technique. The average age was 57.2 (+/- 7.7) years. The average follow up period was 40.3 months (9-63 months). All patients returned to heavy labor. No revision surgery was needed within the follow up period. Range of motion (ROM) and grip strength did not significantly improve. Patient satisfaction was high despite imperfect results. Conclusions Minimal arthroplasty as described may provide a temporary solution for active patients with symptomatic early wrist arthritis who are not candidates for salvage wrist surgery. Longer -term follow up as well as investigation of additional stabilization procedures is necessary.

The purpose of this study was to establish a normal measure of scaphoid position in the radioulnar plane in standard neutral, radial and ulnar deviation posteroanterior radiographs. This measurement may allow indirect evaluation of the radiocarpal ligaments and comparison between normal and pathologic states (following radius fractures, perilunate dislocations). Measurements were trialed on 74 normal wrist radiographs and 25 cadaver wrists. We evaluated the distance between the radial styloid and the scaphoid and corresponding scaphoid width. The ratio of distance/width at the mid styloid level (0.35, imprecision SD = 0.1) had the lowest random error and is therefore the most precise measurement of true scaphoid translation. This measurement is independent of scapholunate ligament integrity and may provide a better assessment of the radiocarpal component of ulnar translational instability. Abnormal movement of the scaphoid in the radioscaphoid joint likely reflects ligamentous injury. Identifying and addressing these injuries may prevent the development of arthritis.

Thumb carpometacarpal (CMC) joint arthritis is a common and debilitating condition. The mainstay of treatment is conservative management. Surgery is only indicated following failure of a prolonged and comprehensive trial of nonoperative treatment. Once surgery has been designated, an array of surgical alternatives exist, all of which provide specific benefits and disadvantages. The different surgical options and their results are reviewed. The specific surgery will vary depending on the surgeon`s experience and preference taking into account the patient`s specific needs. The most commonly performed operative management at this time consists of trapeziectomy with ligament reconstruction, but most procedures can produce high patient satisfaction and in general, the results of surgical treatment are good.

Proximal interphalangeal (PIP) joint contractures are notoriously difficult to treat. Best results are obtained with early mobilization and splinting, though a high level of adherence is critical for a good outcome. A new roll-on splint that aims to increase motion with minimal difficulty was used. The patient described here with moderate PIP joint contractures (30 degrees -60 degrees ) was treated successfully using this splint. The splint design and therapy protocol are described. The patient was treated for 12 weeks with good adherence to therapy and splinting. Total active motion increased by 87% in the index finger and 108% in the ring finger. Grip, pinch, and tip-pinch strengths increased. The Disabilities of the Arm, Shoulder and Hand score improved from 26.7% to 2.5%. At 3 months, the patient returned to work. Though this case illustrates some of the advantages and disadvantages of the new splint, further study is necessary to evaluate the splint and compare it with other existing forms of treatment for PIP joint contractures.

We have noted a peak in induration and tenderness around scars with accompanying symptoms 6-8 weeks after most hand operations. The purpose of this study was to characterise this phenomenon. All consecutive patients treated for fractures of the distal radius through a volar scar were prospectively enrolled. Exclusion criteria included: previous injuries of that wrist, no volar scar, open fractures with considerable soft tissue injury, or injuries to the nerve or vessel, or all three. Patients were evaluated every other week for three months after the operation for the following: tightness, the Vancouver scale, oedema, and range of movement in the wrist. Non-linear mixed effects models were used for analysis. Eighteen patients were evaluated. The primary outcomes included a reduction in pliability from 2.1 (0.6) to 0.9 (0.5), and subjective tightness that decreased from 3.6 (1.8) to 1.5 (2.6). Both pliability and subjective tightness showed a parabolic pattern over time, with a peak at 5.10 (95% confidence interval (CI) 4.36 to 5.84) weeks and 4.12 (2.19 to 6.05) weeks, respectively. Mean (SD) active extension increased from 22.5 (11.4)(o) at 2 weeks to 45.5 (13.4)(o) at 12 weeks. Flexion increased from 19.1 (10.2)(o) to 33.0 (14.7)(o). Oedema decreased from 19.4 (2.1) to 17.3 (1.3) cm. The Vancouver scale decreased from 6.0 (1.9) to 3.4 (1.9), and these variables showed a consistent pattern of change over time. Our results support the existence of a peak in scar symptoms, illustrated by a reduction in pliability and an increase in subjective tightness about 4-5 weeks after the operation. Anticipating this healing pattern can aid in tailoring postoperative management of the scar.

We describe the case of a dorsal proximal triquetral impingement caused by a torn triangular fibrocartilage complex (TFCC) amassed on the repair site at the ulnar styloid. The impinging tissue was removed by simple burring with resultant relief of symptoms. This case illustrates painful impingement of soft tissue on the triquetrum. Possibly, the source of tissue impingement may include different extra-articular or torn intra-articular structures. Soft tissue impingement on the triquetrum may be a cause of ulnar-sided wrist pain following failed TFCC repair.

OBJECTIVE: To compare the effectiveness of an intensive lumbrical splint/stretch combination with 3 less intensive lumbrical splint/stretch combinations on carpal tunnel symptoms and function. DESIGN: Randomized Clinical Trial. SETTING: Outpatient hand therapy clinics. PARTICIPANTS: Volunteers (N=124) with mild to moderate carpal tunnel syndrome. INTERVENTIONS: A 4-week home regimen of nocturnal splints (lumbrical splints or cock-up splints) combined with stretches (lumbrical intensive or general) performed 6 times daily. MAIN OUTCOME MEASURES: The effect of the intervention on carpal tunnel symptoms and function was examined with the Carpal Tunnel Symptom Severity and Function Questionnaire (CTQ) and Disabilities of the Arm, Shoulder, and Hand (DASH). We also evaluated whether subjects obtained surgery at 24 weeks. RESULTS: There were significant main effects over time for all outcome measures at 4, 12, and 24 weeks. There was a significant interaction effect for the CTQ-Function and DASH at 12 weeks. Post hoc analyses indicated significant differences between the lumbrical splint/general stretch and general splint/lumbrical stretch groups and the other 2 groups. At 24 weeks, a significantly greater percentage of subjects in the general splint/lumbrical stretch group achieved a clinically important improvement on the CTQ-Function. By 24 weeks, only 25.5% of subjects had elected to undergo surgery. CONCLUSIONS: A combination of a cock-up splint with lumbrical intensive stretches was the most effective combination for improvements in functional gains at 24 weeks postbaseline. Our findings support further evaluation of this combination as a method of conservative carpal tunnel syndrome treatment.

Glomus tumors are benign neoplasms that develop from normal glomus bodies. These tumors are most commonly found in the nail bed of the hands and are characterized by point tenderness, and temperature sensitivity. Histologically, they are classified into three groups, the least common is glomangiomyoma, which is a variant distinguished by its predominant smooth muscle cellular content. This report describes a patient with a subungual glomangiomyoma that was surgically excised with a favorable outcome. The tumor is unusual for this location; a location common for typical glomus tumors. It presented without the typical associated symptoms of point and temperature sensitivity. This may suggest that the histological type may be more important in predicting the clinical presentation than the anatomical location of the glomus tumor.