Faculty Bibliography

Our purpose was to quantify the Gilula score for measurement of lunate uncovering, to compare it with another method of measurement and to examine the reliability of these measurements in posteroanterior (PA) views in radial and ulnar deviation. Seventy-six normal wrist arthrograms were reviewed retrospectively. Carpal height and lunate uncovering measurements were made. Statistical analysis included mixed effects models to evaluate the difference between the mean measurements in each position. Reproducibility was assessed using imprecision estimates. Normal values for the Gilula method were 40% lunate uncovering in neutral, 49% in radial and 20% in ulnar deviation. There was a statistically significant difference between the values in the different views. Ulnar translation of the carpus can be measured reliably on neutral and radially deviated PA views using the Gilula method, but the different normal values for each view should be used. The Schuind method of measurement is comparable to the Gilula method in the neutral PA view.

Basal joint arthritis of the thumb is commonly treated surgically. Although the results are good, there is still controversy regarding the treatment of young people with low radiographic stages of disease. Our purpose was to evaluate the durability of a tendon arthroplasty procedure in this population. Thirty patients aged 55 years or under, with early stage arthritis, were evaluated. Eight patients were available for long-term (average 86 months) follow-up. No deterioration in the strength and mobility of the operated thumbs in the long-term was found. There was a significant increase in tip pinch strength between short- and long-term follow-up evaluations. This study supports the durability of this surgery in younger patients, potentially reducing the need for multiple surgeries.

We present a report of a diabetic patient with an infection of his left thumb and thenar eminence. Standard cultures of drainage and tissue biopsy were unrevealing. The infection progressed despite empiric antibacterial agent therapy and multiple debridements. Two intraoperative tissue biopsies revealed a yellow-pigmented, rapidly growing Mycobacterial nontuberculous species. The organism was identified as Mycobacterium monacense, a newly described species. The patient was cured with a 6-week course of clarithromycin and levofloxacin.

BACKGROUND: Knowledge of the relationship of the palmar arches to anatomical landmarks would decrease iatrogenic injuries, facilitate treatment of vascular occlusive disease, and ease interpretation of abnormal arteriograms. The purpose of this study was to identify the location of the palmar arches in relation to surface and bony landmarks. METHODS: The palmar arches in 48 cadavers were identified through dissection. The most distal points of the palmar arches were measured in relation to Kaplan's cardinal line, the distal wrist crease, and the carpometacarpal joint of the ring finger. The distances of the palmar arches to the radiocarpal joint were measured on 30 arteriograms. RESULTS: The superficial palmar arch and deep palmar arch were found to be on average 15.3 +/- 8.60 mm and 6.70 +/- 4.82 mm distal to Kaplan's cardinal line, respectively. The superficial palmar arch was found to be on average 51.8 +/- 7.56 mm distal to the distal wrist crease, while the deep palmar arch was only 40.1 +/- 7.92 mm from the distal wrist crease. The average distances from the superficial palmar arch and deep palmar arch to the carpometacarpal joint of the ring finger were 32.2 +/- 6.33 mm and 18.3 +/- 4.64 mm, respectively. On arteriography, the superficial palmar arch and deep palmar arch were on average 50.3 +/- 8.61 mm and 44.89 +/- 4.77 mm, respectively, from the radiocarpal joint. CONCLUSIONS: The superficial and deep palmar arches were located at consistent distances from easily identifiable surface and bony landmarks. Knowledge of these predictable anatomical relations would aid clinicians in surgical dissection, treatment of vascular occlusive disease, and interpretation of abnormal arteriograms when only one arch is present.

A case of acute compartment syndrome of the forearm, resulting from contrast dye extravasation that presented as upper extremity ischemia, is described. Timely surgical intervention resulted in an excellent outcome. When extravasation of dye occurs, the patient should be evaluated for compartment syndrome despite the possible lack of typical symptoms.

Chronic radial wrist pain with no radiographic evidence of scapholunate instability or other wrist disease can be difficult to diagnose and treat. Our purpose was to evaluate the results of an operation to treat chronic radial or periscaphoid wrist pain that has failed to respond to conservative treatment. We examined the scapholunate ligament and performed a dorsal capsulodesis. One hundred-and-two patients were reviewed retrospectively. Casenotes were available for 88 patients. Function, pain, range of movement (ROM), and grip and pinch strengths were evaluated. Twenty (23%) of the patients were found to have a scapholunate ligament tear of 0-30%, 55 (61%) had a tear of 30%-60%, and 14 (16%) had a tear of 60%-100%. Mean postoperative grip strength was 29.5 kg (80% of the normal side). Postoperative range of movement was significantly limited in flexion compared with the normal side. All patients returned to their previous employment. Seventy (80%) of the patients described improvement in pain and function. Twenty-two (25%) required further operation on the same wrist. This procedure may be indicated in patients with chronic radial wrist pain and no overt instability that is resistant to conservative treatment. It has minimal morbidity and gives good results.

Use of different imaging modalities in the diagnosis of peripheral nerve pathology has been growing steadily. This review attempts to summarize their use, particularly with regard to ultrasound and magnetic resonance imaging, and their practical applications in the clinical setting.

BACKGROUND: A possible complication of open, limited incision or endoscopic carpal tunnel release is transection of the thenar branch of the median nerve or the superficial palmar arch. Knowledge of the anatomy of these structures in relationship to the transverse carpal ligament is critical in preventing these complications. The authors investigated these anatomical relationships using cadaveric dissections. METHODS: Forty-eight fresh cadaver hands were analyzed. The distance between the distal transverse carpal ligament and the superficial palmar arch, the distance between the distal transverse carpal ligament and the origin of the thenar branch of the median nerve, and the length of the transverse carpal ligament were measured. RESULTS: In the 48 specimens, the thenar branch of the median nerve was extraligamentous in 44 (92 percent), subligamentous zero (0 percent), and transligamentous in four (8 percent). The thenar branch of the median nerve contained one branch in 28 (58 percent) and multiple branches in 20 specimens (42 percent). The average distance from the distal transverse carpal ligament to the superficial palmar arch was 18.8 +/- 0.6 mm (95 percent CI, 17.6 to 20.1 mm) and that to the thenar branch of the median nerve was 6.9 +/- 0.4 mm (95 percent CI, 6.0 to 7.8 mm) (p < 0.0001). The average length of the transverse carpal ligament was 28.5 +/- 0.8 mm (95 percent CI, 26.9 to 30.1 mm). CONCLUSIONS: The anatomical relationships among the superficial palmar arch, thenar branch of the median nerve, and distal transverse carpal ligament were found to be consistent. This will assist the hand surgeon in preventing specific complications regardless of the method of carpal tunnel release chosen.

BACKGROUND: Diagnosis of carpal tunnel syndrome remains clinical, despite many objective clinical and electrophysiologic tests. There is also a need to objectively assess the severity of involvement and the need for surgery, and to document response to treatment. The authors evaluated a hand-held strength-testing device for assessment of abductor pollicis brevis strength in patients with carpal tunnel syndrome. METHODS: Sixty-two hands in 50 patients (39 women and 11 men) aged 26 to 57 years were examined. All hands were evaluated before and 6 weeks after surgery. Nineteen hands were available for 7-year follow-up. RESULTS: Abductor pollicis brevis strength following carpal tunnel release increased significantly from a mean of 2.3 kg to 3.1 kg. The strength further increased in all long-term follow-up patients. CONCLUSIONS: Quantitative strength testing can be used to document changes in abductor pollicis brevis strength in response to treatment in patients with carpal tunnel syndrome. Further study is needed to assess the reliability of this testing method using multiple examiners in patients with carpal tunnel syndrome, and to evaluate the utility of using this device in tracking the long-term outcome of patients after carpal tunnel release.