Basal Joint Arthritis A Review of Pathology, History, and Treatment [Historical Article]
The basal joint is a collection of articulations at the base of thumb that serve an important function in the overall dexterity of the hand. The unique anatomy of the basal joint provided many evolutionary advantages to the human hand, but also made this joint susceptible to arthrosis and degenerative changes. Surgical treatment of basal joint arthritis has continued to evolve since it was first described in 1949, including excisional arthroplasty, tendon interposition, ligament reconstruction, implant arthroplasty, and arthroscopy. A review of the pathoanatomy, history, and surgical treatments are assessed including a critical review of the literature.
Bridging the Gap in Peripheral Nerve Repair
Peripheral nerve injuries following trauma present an ongoing challenge to the hand surgeon. This review presents an overview of the topic with a historical perspective. Nerve anatomy and nerve injury classifications are discussed followed by a description of the biology of nerve regeneration. Methods used to bridge gaps in peripheral nerve repair are discussed in detail with a critical appraisal of the most recent literature. Recommendations for surgical treatment are formulated based on evidence-based medicine.
Impact of Joint Position and Joint Morphology on Assessment of Thumb Metacarpophalangeal Joint Radial Collateral Ligament Integrity
PURPOSE: A 2-part biomechanical study was constructed to test the hypothesis that coronal morphology of the thumb metacarpophalangeal joint impacts the assessment of instability in the context of radial collateral ligament (RCL) injury. METHODS: Fourteen cadaveric thumbs were disarticulated at the carpometacarpal joint. Four observers measured the radius of curvature of the metacarpal (MC) heads. In a custom jig, a micrometer was used to measure the RCL length as each thumb was put through a flexion and/or extension arc under a 200 g ulnar deviation load. Strain was calculated at maximal hyperextension, 0 degrees , 15 degrees , 30 degrees , 45 degrees , and maximal flexion. Radial instability was measured with a goniometer under 45 N stress. The RCL was then divided and measurements were repeated. Analysis of variance and Pearson correlation metrics were used. RESULTS: The RCL strain notably increased from 0 degrees to 30 degrees and 45 degrees of flexion. With an intact RCL, the radial deviation was 15 degrees at 0 degrees of flexion, 18 degrees at 15 degrees , 17 degrees at 30 degrees , 16 degrees at 45 degrees , and 14 degrees at maximal flexion. With a divided RCL, instability was greatest at 30 degrees of flexion with 31 degrees of deviation. The mean radius of curvature of the MC head was 19 +/- 4 mm. Radial instability was inversely correlated with the radius of curvature to a considerable degree only in divided RCL specimens, and only at 0 degrees and 15 degrees of flexion. CONCLUSIONS: The RCL contributes most to the radial stability of the joint at flexion positions greater than 30 degrees . The results suggest that flatter MC heads contribute to stability when the RCL is ruptured and the joint is tested at 0 degrees to 15 degrees of metacarpophalangeal flexion. CLINICAL RELEVANCE: The thumb MC joint should be examined for RCL instability in at least 30 degrees of flexion.
Diagnosis and treatment of finger deformities following injuries to the extensor tendon mechanism
Injuries to the finger extensor apparatus are very common and may produce chronic deformity and loss of function. Diagnosis is contingent on an understanding of the complex anatomy of this region as well as the ability to perform a careful physical examination. Immobilization is usually the most effective treatment of acute problems. Surgery is often necessary for chronic conditions, but the results are much less predictably corrective.
Correction of the claw hand
Intrinsic paralysis can be the manifestation of a variety of pathologic entities (stroke, cerebral palsy, Charcot-Marie-Tooth, muscular dystrophy, leprosy, trauma, cervical disease, and compressive and metabolic neuropathies). Patients present with a spectrum of clinical findings dependent on the cause and severity of the disease. The 3 main problems caused by intrinsic weakness of the fingers are clawing with loss of synchronistic finger flexion, inability to abduct/adduct the digits, and weakness of grip. Clawing is defined as hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints. This article describes the clinical evaluation and surgical treatment options for claw hand
Madelung's deformity: a review [Case Report]
Madelung's deformity is a rare condition of the wrist characterized by a shortened distal radius with volar-ulnar curvature and a dorsally prominent distal ulna. It occurs predominantly in adolescent females who present with pain, decreased wrist mobility, and deformity. Although its aetiology remains unclear, its treatment is becoming more refined. Several different surgical techniques have recently been described in the literature. This review addresses Madelung's deformity and suggests an algorithm for management based on current literature and the authors' own clinical experience
Intraosseous and extraosseous attachments of flexor tendon to bone: a biomechanical in vivo study in rabbits
There are 2 popular methods of repairing flexor tendons to the distal phalanx and attaching a free tendon graft to bone: intraosseous, by implanting the tendon into a bony tunnel, and extraosseous, by suturing the tendon to the cortical surface after elevating the periosteum. An in vivo study was designed to determine whether one method is stronger than the other. The profundus flexor of the third and fourth toes of the hind paw of adult rabbits was divided and reattached to the middle phalanx using either an intraosseous tunnel or an extraosseous suture. Half the rabbits were killed after 3 weeks, the other half after 8 weeks. Repairs were then tested to failure, using an Instron device, and compared with the same tendons in the nonoperated limbs. The repaired tendons demonstrated similar strength 3 weeks and 8 weeks after surgery but were significantly weaker than the nonoperated tendons. The importance of this study is that it gives equal credence to these usual methods of tendon attachment
Safety and efficacy of the infraclavicular nerve block performed at low current
It has recently been suggested that peripheral nerve or plexus blocks performed with the use of a nerve stimulator at low currents (<0.5 mA) may result in neurologic damage. We studied the infraclavicular nerve block, performed with the use of a nerve stimulator and an insulated needle, in a prospective evaluation of efficacy and safety. During a one-year period, 248 patients undergoing infraclavicular nerve block were evaluated for block success rate and incidence of neurologic complication. All blocks were performed with the use of a nerve stimulator and an insulated needle at < or =0.3 mA. Success rate was 94%, which increased to 96% with surgical infiltration of local anesthetic. There were no intraoperative or immediate postoperative complications noted. After one week, only one patient had a neurologic complaint, and this was surgically related, referable to surgery performed on the radial nerve. We conclude that infraclavicular nerve blocks performed at low currents (< or =0.3 mA) are safe and effective
Thumb metacarpophalangeal ulnar collateral ligament injuries: a biomechanical simulation study of four static reconstructions
PURPOSE: To determine the optimal tunnel placement positions for tendon graft reconstruction of chronic thumb metacarpophalangeal (MCP) ulnar collateral ligament injuries that would stabilize the joint while maintaining motion. METHODS: Four commonly used tunnel placement methods were simulated on a cadaveric model using fresh-frozen thumbs and a suture/screw construct. The methods were as follows: (1) triangular configuration with apex proximal, (2) triangular configuration with apex distal, (3) cruciate configuration, and (4) parallel configuration. Stability was tested by valgus loading at 0 degrees and 30 degrees , and range of motion was tested by loading the thumb tendons. Statistical analysis was performed by 1-way analysis of variance testing. RESULTS: Valgus load stability testing at 0 degrees and 30 degrees showed that all 4 reconstruction methods stabilized the MCP joint compared with the fully sectioned state. The amount of stability achieved was not significantly different between the 4 methods. Only the reconstruction method, however, with a triangular configuration with the apex proximal restored flexion/extension range of motion not significantly different from the intact state. The other 3 methods resulted in significantly decreased range of motion. CONCLUSIONS: The reconstruction tunnel positioning of triangular configuration with apex proximal stabilizes the thumb MCP joint while maintaining flexion/extension range of motion. We recommend this configuration for chronic MCP joint injuries in which the native ulnar collateral ligament is inadequate and tendon graft reconstruction is performed
A meta-analysis of the literature on distal radius fractures: review of 615 articles
A structured meta-analysis of the available literature was performed to evaluate the outcome of the treatment of displaced intra-articular fractures of the distal radius. A comprehensive search of Medline using the key words 'radius' and 'fracture' revealed over 4,000 articles. After limiting the search to clinical trials in English and excluding pediatric and geriatric age groups as well as biomechanical and animal studies, 615 abstracts were identified in the period from 1976 to May 1998. Thirty-one articles met the inclusion and exclusion criteria. These included two prospective randomized comparative trials, two non-randomized comparative trials, one half prospective case series and half historical control, and 27 papers on case series. Four papers dealt with external fixation versus closed reduction and cast treatment and one paper looked at open reduction internal fixation with or without additional external fixation. There was insufficient data to perform a scientific meta-analysis because of the poor quality of the studies and lack of a uniform method of outcome assessment. However, the data from the comparative trials showed that external fixation was favored over closed reduction and casting. Additionally, comparing the results of the case series showed that external fixation was superior to internal fixation