Faculty Bibliography

The wrist is the most commonly involved joint in the upper extremity of patients with rheumatoid arthritis. Up to 75% of patients will develop wrist problems during the course of the disease. Cartilage degeneration and synovitis cause the typical skeletal erosions, ligamentous laxity, deformity, and tendon problems seen in the disease. Treatment involves a multidisciplinary approach with careful coordination of the primary care physician, rheumatologist, orthopaedic surgeon, and other members of the care team. As rheumatoid arthritis is a systemic, polyarticular disease, it is critical to consider the entire patient in any management decision. Initial management is usually non-operative and involves pharmacological treatment, activity modification, and possibly bracing. Operative treatments are geared to limit the negative effects of the disease, namely pain, loss of function, and deformity. Numerous procedures have been described. Common procedures from tenosynovectomy/synovectomy, distal radio-ulnar joint arthroplasty, arthrodesis, and total wrist arthroplasty are reviewed

Scaphoid fractures are a common injury in young, active populations. Non-displaced fractures have a high union rate if promptly treated with cast immobilization. Displaced fractures and proximal pole fractures are best treated with operative fixation. There are a variety of techniques and implants available to the surgeon. The surgical approach and fixation device should be based on fracture characteristics and surgeon experience. Operative fixation of non-displaced fractures is an option in patients who would prefer to avoid prolonged cast immobilization

Proximal pole fractures of the scaphoid are well suited for comprehension screw fixation. A dorsal approach allows for direct visualization of the fracture site, accurate reduction, and internal fixation. Bone grafting can also be achieved through the same incision without additional significant dissection. Successful uncomplicated union in the majority of cases with a considerably shortened period of immobilization has lead to a growing interest in this surgical procedure

Ten patients with chronic dorsal fracture subluxation of the distal interphalangeal joint were managed over 5 years with volar plate advancement arthroplasty. The mean time from injury to definitive surgical treatment was 8 weeks (range, 2 weeks to 4 months). All injuries were characterized by volar comminution and impaction of the distal phalanx, with associated dorsal subluxation. Surgical treatment included volar plate advancement arthroplasty and K-wire fixation of the reduced joint for 4 weeks. All patients were evaluated at an average postoperative duration of 25 months (range, 10-60 months). The average arc of motion of the distal interphalangeal joint of the 4 fingers (6) was 42 degrees and of the interphalangeal joint of the thumb (4) was 51 degrees. All patients had a residual flexion contracture averaging 12 degrees (range, 6 degrees to 25 degrees ). Volar plate advancement arthroplasty is an effective treatment for chronic distal interphalangeal joint dorsal fracture subluxation

Forty patients with Galeazzi fracture-dislocations were treated with open reduction and internal fixation of the radial shaft fracture. Intraoperative distal radioulnar joint (DRUJ) instability after anatomic reduction was managed with supplemental wire transfixion of the DRUJ (10 patients) or open reduction and triangular fibrocartilage complex repair (3 patients). Two patterns of fracture-dislocation were identified based on the location of the radial shaft fracture. Twenty-two type I fractures were in the distal third of the radius within 7.5 cm of the midarticular surface of the distal radius; 12 of these cases were associated with intraoperative DRUJ instability. Eighteen type II fractures were in the middle third of the radial shaft more than 7.5 cm from the midarticular surface of the distal radius. Only one of these fractures had intraoperative DRUJ instability after open reduction and internal fixation of the radial shaft fracture. A high index of suspicion, early recognition, and acute treatment of DRUJ instability will avoid chronic problems in this complex injury

Fourteen consecutive patients with acute displaced scaphoid waist fractures were treated with open reduction and internal fixation. The operative technique consisted of anatomic reduction of the displaced scaphoid waist fracture, correction of carpal instability, radial bone grafting for comminution, and internal fixation with K-wires or Herbert screw. The patients were evaluated an average of 26 months (range, 4-48 months) after surgery. Thirteen of the 14 (93%) fractures united. The average time to union was 11.5 weeks (range, 8-20 weeks). Fracture union was confirmed with trispiral tomography. Final radiographic assessment consistently revealed a healed scaphoid fracture, restored intrascaphoid alignment, and no evidence of carpal instability. All patients regained functional wrist range of motion (wrist extension, 57 degrees; wrist flexion, 52 degrees ) and grip strength. Open reduction and internal fixation of acute displaced scaphoid waist fractures restores scaphoid alignment and leads to predictable union. Early operative intervention avoids malunion and carpal instability that often occurs with closed management of these complex fractures

Distal radius fractures commonly are sustained by athletes during competition. Typically, these are high energy injuries with severe displacement, metaphyseal comminution, and articular surface disruption. Each fracture is distinguished by its degree of articular displacement, stability, and reducibility. Management is contingent on recognition of the variable magnitude of articular disruption and skillful treatment based on specific fracture configuration

Twelve patients with chronic stage III or stage IV perilunate dislocations were managed over the past 7 years by proximal row carpectomy. All dislocations were untreated or incompletely reduced for a minimum of 8 weeks after injury. The mean time from injury to definitive treatment was 15 weeks (range, 8 weeks to 6 months). Surgical management was inclusive of a dual dorsal and volar approach. Median nerve decompression, lunate excision, and capsuloligament repair was performed volarly and scaphoid and triquetrum carpectomy was accomplished dorsally. Temporary radio capitate K-wire fixation during early soft tissue healing was uniformly performed. All patients were evaluated at an average postoperative duration of 40 months (range, 28 months to 7 years). Marked relief of wrist pain and median nerve dysesthesias was routinely achieved. Effective wrist range of motion and grip strength were restored. Untreated stage III and IV chronic perilunate dislocation treated by proximal row carpectomy eliminates pain and restores function to a severely injured wrist