Wrist anatomy and surgical approaches

3D geometric morphometric analysis of the distal radius insertion sites of the palmar radiocarpal ligaments indicates a relationship between wrist anatomy and unique locomotor behavior in hylobatids

OBJECTIVES

The objective of this study is to explore the anatomical differences in the insertion sites of the palmar radiocarpal ligaments between hylobatids and other hominoids that may be related to their different locomotor behaviors.

MATERIALS AND METHODS

The morphology of the insertion sites of the palmar radiocarpal ligaments was analyzed with three-dimensional geometric morphometrics (3D GM) in the distal radial epiphysis of 44 hylobatids, 25 Pan, 31 Gorilla and 15 Pongo.

RESULTS

Relative to other hominoids, hylobatid insertion sites of the palmar radiocarpal ligaments were relatively larger and the insertion site of the short radiolunate ligament had a palmar orientation.

DISCUSSION

Larger palmar radiocarpal ligaments in hylobatids can help stabilize the wrist during the radial and ulnar displacement that occurs in ricochetal brachiation, the characteristic locomotor behavior of hylobatids, and compensate for the large traction loads on the wrist during extended-elbow vertical climbing.

Initial Outcomes of a Novel High-Visibility Endoscopic Carpal Tunnel Release Technique

Background  A large variety of endoscopic carpal tunnel release methods have been described in efforts to shorten recovery time, reduce scar discomfort, and allow earlier return to work. The majority of existing techniques are the modifications of the Agee, Chow, and Menon techniques, all of which require dedicated equipment that can increase facility and surgical fees for the patient and institution. We present a novel high-visibility endoscopic carpal tunnel release technique that uses common hand surgery instruments available in all surgical units, without requiring disposable or custom devices. Description of Technique  The cases were performed under local anesthesia using routine reusable instruments and a conventional 2.5-mm 30-degree small joint arthroscope. Following proximal dissection, a clear, colorless, plastic shield was created from a standard syringe that offered a 360-degree vision of the carpal tunnel and protection of the median nerve. Release of the transverse carpal ligament was performed under full arthroscopic vision using Metzenbaum dissection scissors. Methods  This pilot study analyses the first nine cases in eight patients who were operated on using this technique, with a minimum of 6 months of follow-up. Results  No peri- or postoperative complications were encountered. All patients demonstrated significant improvements in the Disabilities of the Arm, Shoulder, and Hand score, the Boston Carpal Tunnel Questionnaire score, and a visual analog score for pain. Conclusion  The high-visibility endoscopic carpal tunnel release technique is safe and effective, and offers a viable cost-reducing alternative to the existing endoscopic methods for carpal tunnel syndrome. Future comparative trials are required to validate these findings in a larger series. Level of Evidence  This is a Level IV study.

Three-dimensional geometric morphometric analysis of the distal radius insertion sites of the palmar radiocarpal ligaments in hominoid primates

OBJECTIVES

To identify anatomic differences in the insertion sites of the palmar radiocarpal ligaments in different species of hominoid primates that may be related to their different types of locomotion.

MATERIALS AND METHODS

We have used three-dimensional geometric morphometrics (3D GM) to analyze the distal radius ligament insertion sites in 31 Homo sapiens, 25 Pan troglodytes, 31 Gorilla gorilla, and 15 Pongo pygmaeus. We have also dissected the radioscaphocapitate (RSC), long radiolunate (LRL) and short radiolunate (SRL) ligaments in six H. sapiens and five P. troglodytes to obtain quantitative values that were then compared with the results of the 3D GM analysis.

RESULTS

H. sapiens had a relatively larger insertion site of the RSC + LRL ligament than the other hominoid primates. P. pygmaeus and P. troglodytes had a relatively large SRL ligament insertion site with a palmar orientation. In G. gorilla, the two ligament insertion sites were relatively smaller and the SRL insertion site had an ulnopalmar orientation.

DISCUSSION

The morphological differences observed can be related to the types of locomotion used by the different species and to quantitative data obtained from the dissection of ligaments in H. sapiens and P. troglodytes. 3D GM analysis of ligament insertion sites can help in interpreting the types of locomotion used by extinct hominoid primates through the analysis of preserved fossilized fragments of the distal radius.

Conservative Treatment of Distal Radius Fractures: A Prospective Descriptive Study

BACKGROUND

Disability of the upper limb is one of the consequences of distal radius fracture (DRF). The outcome of DRF treatment is based on objective clinical variables, as strength or range of movement (ROM); sometimes these variables do not correlate with the functional level of the patient. The principal objective of our study was to assess the repercussion of conservative treatment of DRF on upper limb disability.

METHODS

This is a retrospective review of prospectively collected data. We collected data of 61 nonconsecutive DRFs treated conservatively from July 2007 to August 2008.

RESULTS

Average Disabilities of the Arm, Shoulder and Hand (DASH) score before fracture was 20.8 points; average DASH score after the fracture was 42.6. There was a significant increase in the upper limb disability after 1 year of follow-up in the patients treated conservatively ( P < .001; size effect, 1.06). Average radial inclination, radial tilt, and radial length were 18.18°, 3.35°, and 5.76 mm, respectively. Average ROM for flexion-extension was 100.6° and for pronation-supination 144.0°. ROM for flexion-extension of the unaffected wrist was 128.2° and for pronation-supination 172.4°. We did not find any significant statistical correlation between the increase in disability and the decrease in the ROM ( P > .05). We did not find any significant statistical correlation between the increase in the disability and the worsening in the radiological parameters ( P > .05). Our results confirm the hypothesis that the conservative treatment of DRF produced an increase in the upper limb disability after 1 year of follow-up.

CONCLUSIONS

Our study does not show a correlation between the increase in upper limb disability and the decrease in wrist ROM. Our study did not find a correlation between radiological measures and DASH scores.

Imaging Findings of the Distal Radio-Ulnar Joint in Trauma

Traumatic lesions of the distal radio-ulnar joint (DRUJ) occur frequently in conjunction with fractures of the distal radius. They are a common cause of pain and limited range of motion after distal radial fractures. Due to the complex anatomy they are however often ignored or underappreciated. Distal radial fractures and luxations of the DRUJ often disturb the normal curvature of the radial notch and cause damage to the cartilage of this joint. The growth of the radius may be disrupted, resulting in a positive ulnar variance, and possibly give rise to complications such as ulnar abutment and motion restriction.

Ulnar styloid fractures – sometimes barely visible on plain film – may give rise to symptomatic bony pseudarthrosis, dislocation and laceration of the tendon of the m. extensor carpi ulnaris and a rare posttraumatic deformity of the ulnar epiphysis. Also the possibility of lesions at the adjacent triangular fibrocartilage complex and the joint capsule should be kept in mind.

This paper presents a pictorial review of the complex functional anatomy and pathologic conditions of this joint and emphasises why the DRUJ should be evaluated independently and thoroughly. The merit of each imaging modality is mentioned.

A correction article relating to Fig. 2 and Fig. 27 can be found here: http://dx.doi.org/10.5334/jbr-btr.966

Accuracy of sonographically guided and palpation guided scaphotrapeziotrapezoid joint injections

OBJECTIVES

The purpose of this study was to determine and compare the accuracies of sonographically guided and palpation guided scaphotrapeziotrapezoid (STT) joint injections in a cadaveric model.

METHODS

A clinician with 6 years of experience performing sonographically guided procedures injected 1.0 mL of a diluted latex solution into the STT joints of 20 unembalmed cadaveric wrist specimens using a palmar approach. At a minimum of 24 hours after injection, an experienced clinician specializing in hand care completed palpation guided injections in the same specimens using a dorsal approach and 1 mL of a different-colored latex. A fellowship-trained hand surgeon blinded to the injection technique then dissected each specimen to assess injection accuracy. Injections were graded as accurate if the colored latex was found in the STT joint, whereas inaccurate injections resulted in no latex being found in the joint.

RESULTS

All sonographically guided injections were accurate (100%; 95% confidence interval, 81%-100%), whereas only 80% of palpation guided injections were accurate (95% confidence interval, 61%-99%). Sonographically guided injections were significantly more accurate than palpation guided injections, as determined by the ability to deliver latex into the joint (P < .05).

CONCLUSIONS

Sonographic guidance can be used to inject the STT joint with a high degree of accuracy and is more accurate than palpation guidance within the limits of this study design. Clinicians should consider using sonographic guidance to perform STT joint injections when precise intra-articular placement is desired. Further clinical investigation examining the role of sonographically guided STT joint injections in the treatment of patients with radial wrist pain syndromes is warranted.

Sonographically guided distal radioulnar joint injection: technique and validation in a cadaveric model

Distal radioulnar joint (DRUJ) disorders are uncommon but important causes of ulnar-sided wrist pain and disability. Fluoroscopically guided injections may be performed to diagnose or treat DRUJ-related pain or as part of a diagnostic arthrogram. Sonographic guidance may provide a favorable alternative to fluoroscopic guidance for distal DRUJ injections. This report describes and validates a sonographically guided technique for DRUJ injections in an unembalmed cadaveric model. An experienced clinician used sonographic guidance to inject diluted colored latex into the DRUJs of 10 unembalmed cadaveric specimens. Subsequent dissection by a fellowship-trained hand surgeon confirmed accurate injections in all 10 specimens. Two cases of ulnocarpal flow, indicative of triangular fibrocartilage injury, were noted during injection and subsequently confirmed during dissection. Clinicians should consider using sonographic guidance to perform DRUJ injections when clinically indicated. Further research should explore the efficacy of sonographically guided DRUJ injections to treat patients with painful DRUJ syndromes or to evaluate the triangular fibrocartilage complex in patients with ulnar wrist pain syndromes.

Acute management of hand burns

Hand burns occur commonly either as part of more extensive burn injuries or in isolation. Optimal management requires careful examination, appropriate wound care, timely surgical excision if warranted, and aggressive range-of-motion therapy.