Changes in hand function following wrist arthrodesis in cerebal palsy

Eleven wrists in ten patients with cerebral palsy underwent wrist arthrodesis. All patients were reviewed between 6 and 121 months after surgery. Operative technique involved AO plate fixation in nine wrists. When the distal radial physis was still open (two wrists), stabilization was achieved using K-wires. A proximal row carpectomy was performed in eight patients. Soft tissue releases were necessary in three wrists. The procedure achieved its aim of improving hygiene and cosmesis. Functional improvement in the hand was noted in eight wrists. Function was consistently improved in athetoid patients.     

Treatment of distal radioulnar disorders

Twenty-nine wrists of 29 patients were treated with three procedures: distal ulnar resection (Darrach's procedure), distal ulnar recession, or hemiresection-interposition arthroplasty. The indications were pain and limitation of motion associated with primary osteoarthritis of the distal radioulnar joint, derangement after distal forearm bone fracture, Madelung's deformity, and distal radioulnar sprain. The age of the patients averaged 48.3 years. Follow-up averaged 1 year and 9 months. Radiographic evaluations were done preoperatively and postoperatively. Relief of pain was good in the wrists treated by Darrach's procedure; however, diminished grip strength and wrist instability occurred. Relief of pain in the wrists treated by distal ulnar recession and hemiresection-interposition arthroplasty was inferior to that of Darrach's procedure; however, postoperative grip strength increased and wrist instability did not occur.     

Limited wrist fusions

Seventeen patients had wrist fusions done for diseases other than rheumatoid arthritis of the wrist and carpal bones. Arthrodesis was done at the radiocarpal joint in five wrists and at the midcarpal joint in 12. There were 12 men and five women. Ages at the time of operation averaged 42 years. Follow-up ranged from 6 months to 5 years and 5 months, and with an average of 1 year and 10 months. Overall postoperative results were excellent in five wrists, good in seven, fair in two, and poor in three. Wrists with the midcarpal fusion fared better than those wrists with the radiocarpal fusion. Complications included one pseudoarthrosis and one rupture of the flexor pollicis longus tendon. In one of the 17 wrists new osteoarthritic changes surrounding the arthrodesed joints occurred.     

Diagnosis of occult carpal scaphoid fracture: a comparison of magnetic resonance imaging and computed tomography techniques

We investigated 52 consecutive patients (53 wrists) with suspected scaphoid fracture using MRI (0.2 T) within 7 days after the injury. We performed two sequences for the wrist: (1) coronal T1-weighted spin-echo and (2) T2-weighted turbo spin-echo. We also performed four sequences specific for the scaphoid with the plane parallel to the longitudinal axis of the scaphoid: (1) coronal T1-weighted, (2) coronal T2-weighted, (3) sagittal T1-weighted, and (4) sagittal T2-weighted images. In these projections, only one section is enough to cover the scaphoid fracture that definitely eased the diagnosis. In 18 (33%) wrists, the scaphoid fracture was detected on MRI. Computed tomograms (CT) were also taken with angled sagittal and coronal projections in 16 of the 18 wrists in which the scaphoid fracture was detected on MRI. CT revealed ten nondisplaced fractures, three displaced fractures, and three occult fractures. Bone contusion was found in no patients. MRI is a useful modality as a screening for occult scaphoid fracture.     

Hemiresection-interposition arthroplasty of the distal radioulnar joint associated with repair of triangular fibrocartilage complex lesions.

Sixteen wrists of 15 patients with traumatic triangular fibrocartilage complex tears were treated by hemiresection-interposition arthroplasty of the distal radioulnar joint combined with repair of the torn triangular fibrocartilage complex. The surgical procedure was performed to avoid impingement of the ulnar head against the reconstructed triangular fibrocartilage complex. Most of the wrists showed a positive ulnar variance. The average age of the patients was 39 years. Follow-up averaged 41 months. Complete relief of pain was obtained in 10 wrists. Slight pain persisted in 6 wrists, although it was less than before surgery. The range of motion of the wrist joint and forearm improved postoperatively. Grip strength in all wrists increased. Postoperative complications occurred in 7 wrists of 6 patients: reoperation in 2 wrists, fracture in 1, and tendinitis of the extensor carpi ulnaris in 4. All 15 patients subsequently returned to their previous occupations.     

Radiographic studies of the wrist and elbow in cerebral palsy

We retrospectively studied and evaluated radiographs of the bilateral wrists and elbows in 96 patients with cerebral palsy. There were 55 patients (57.3%) with athetospastic quadriplegia, 30 (31.3%) with spastic diplegia, and 11 (11.4%) with spastic hemiplegia. Plain antero-posterior and lateral roentgenograms were taken of both wrists and both elbows. Overall negative ulnar variance was seen in 18.2% of wrists, and, the variance was highest in athetospastic quadriplegia. We could not find any case of Kienb?ck's disease. The radiolunate angle was negative in the wrists of those with athetospastic quadriplegia. Scapholunate dissociation was found in 2 wrists (1%). Four dislocations of the radial head were found in 2 patients (2%). The humero-radial distance and humero-ulnar distance were both narrowed. The formation of osteophytes was mainly found in the humero-ulnar joint, especially in those with athetospastic quadriplegia. Received for publication on April 16, 1999; accepted on Nov. 2, 1999     

Total wrist replacement using the modified Volz prosthesis

Eighteen total wrist arthroplasties in sixteen patients were done using the modified Volz prosthesis. The length of follow-up ranged from twenty-four to sixty-six months, with a mean of forty months. A 100-point scoring system was used to evaluate the outcome. Muscle imbalance developed in five wrists, the carpal component became loose in three wrists, and two prostheses dislocated. In five patients six arthroplasties (33 per cent) were considered to have failed because one reoperation or more was required for loosening of the components in two wrists, dislocation in two wrists, and muscle imbalance in two wrists. Of the remaining twelve arthroplasties (eleven patients) eight (45 per cent) had an excellent result; two (11 per cent), a good; and two (11 per cent), a poor result. The over-all rate of complications was 44 per cent. Patients who had significant preoperative deformity did poorly postoperatively. The surgeon should be prepared to perform other types of arthroplasty or an arthrodesis if the extensor tendons are structurally inadequate, as this may lead to progressive flexion deformity postoperatively.     

Ulnar variance in Kienb?ck's disease

Forty four patients with forty seven wrists suffering from Kienb?ck's disease were re-examined. The mean observation time was 20.5 years. In all forty seven wrists the treatment had been immobilization. Using a standard X-ray projection, and a reliable method of ulnar variance measuring, the ulnar variance was determined by three observers independently. Comparing the result with the ulnar variance in normal wrists we found the so-called "ulnar minus variant" overrepresented in patients with Kienb?ck's disease. However, comparing X-rays taken at the time of diagnosis with X-rays at re-examination, we found in eight out of forty seven wrists that a subchondral bone formation in the distal radium opposite the lunate bone had taken place. This bone formation will tend to enhance the negative value of ulnar variance measurements, and suggests an explanation of the overrepresentation of "ulnar minus variants" in Kienb?ck's disease. Excluding these eight wrists from the material and comparing the mean ulnar variance value in the remaining thirty nine wrists with the mean value in normal wrists no statistical difference was shown. Based on these observations it seems unlikely that the "ulnar minus variant" has any bearing on the cause of Kienb?ck's disease.     

Arthrotomography of the wrist: an experimental and preliminary clinical study

Experimental arthrotomography including posteroanterior and lateral projections was completed in 18 fresh-frozen wrists from cadavers with an average age of 65 years at death. Arthrotomographic findings were correlated with anatomic dissections. Three types of defects of the triangular fibrocartilage complex were clearly defined in 38% of wrists. Chondromalacia was present in 24% of wrists, in all cases on the ulnar half of the proximal surface of the lunate bone. The palmar radiocarpal ligaments (radiocapitate and radiotriquetral) were visible in all specimens. Experimental arthrotomography appears to be useful in defining the nature and location of soft tissue pathology in clinical practice. Clinical arthrotomography was performed in 16 patients, all with a syndrome of chronic wrist pain. Pathologic findings were observed in 11 wrists, including four perforations of the triangular fibrocartilage complex, two cases of chondromalacia of the lunate, one tear in each of the scapholunate and lunotriquetral ligaments, three occult palmar ganglia, and one recurrent dorsal ganglion. The soft tissues in five wrists were normal. The preliminary clinical experience with wrist arthrotomography has yielded results that have significantly affected the care of patients, including the planning of operative treatment and patient counseling.     

Fate of failed Meuli total wrist arthroplasty

Sixteen Meuli wrist arthroplasties in 13 patients suffering mainly from rheumatoid arthritis were revised for failure. Causes for failure were mechanical problems with the implant in three wrists, soft tissue problems in two wrists and a combination of mechanical failure and soft tissue problems in 11 wrists. Management included 11 revision arthroplasties in ten wrists, four arthrodeses and two primary soft tissue reconstructions. Twenty-six additional soft tissue procedures were required in association with the revision arthroplasties or arthrodeses. Five of the 11 revision arthroplasties had to be converted to arthrodeses after an average of 5 (range 3-8) years. After removal of a failed wrist implant union of the salvage arthrodesis was difficult to achieve in two of the nine instances. This series demonstrates that revision arthroplasty may be a useful alternative to arthrodesis for the salvage of primary wrist arthroplasties in rheumatoid patients. However, complications and reoperations may occur after both revision arthroplasty and arthrodesis.     

Radiolunate arthrodesis: A procedure for stabilising and preserving mobility in the arthritic wrist

We carried out arthrodesis of the radiolunate joint in 46 wrists (38 patients) for pain and ulnar translation of the carpus because of rheumatoid (42) or psoriatic arthritis (4). At follow-up, three patients had died and in three (1 bilateral) an additional midcarpal arthrodesis had been undertaken. The remaining 32 patients (39 wrists) were evaluated after a mean of five years. The clinical results were good with a mean visual analogue score of 8.3 for pain, 7.2 for hand function and 9 for overall satisfaction. Except for palmar flexion, mobility was equal to or better than before operation. Radiologically, there was deterioration of the midcarpal joint with an increase in the Larsen score from 1.8 to 2.7 (p < 0.001), some decrease in carpal height and recurrence of carpal translation. Radiolunate arthrodesis gives good clinical results at five years although there is some deterioration radiologically.     

Treatment of de Quervain tenosynovitis. A prospective study of the results of injection of steroids and immobilization in a splint

In a prospective study of non-operative treatment of de Quervain tenosynovitis, ninety-nine wrists of ninety-five consecutively seen patients who had this diagnosis had an injection of one milliliter of a 1 per cent lidocaine solution and one milliliter of a suspension containing forty milligrams of methylprednisolone acetate. Twelve patients (twelve wrists) were lost to follow-up. Of the remaining eighty-seven wrists, fifty-four (62 per cent) had a satisfactory outcome at a mean of eighteen months (minimum follow-up, twelve months). The duration of symptoms before treatment did not affect the outcome. The result in thirty-three wrists (38 per cent) was considered unsatisfactory. Thirty of these wrists were subsequently treated with operative release of the first dorsal compartment, and twenty-two (73 per cent) of the thirty were found to have a separate compartment for the extensor pollicis brevis. The prevalence of a separate compartment is significantly higher than that in the general population, as shown in anatomical studies of cadavera.     

Arthroscopic repair of peripheral avulsions of the triangular fibrocartilage complex of the wrist: A multicenter study

A multicenter study to assess arthroscopic reconstruction of the peripheral attachment of the triangular fibrocartilage complex was undertaken. A total of 44 patients (45 wrists) from three institutions were reviewed. Twenty-seven of the 45 wrists had associated injuries, including distal radius fracture (4), partial or complete rupture of the scapholunate (7), lunotriquetral (9), ulnocarpal (2), or radiocarpal (2) ligaments. There were two fractured ulnar styloids and one scapholunate accelerated collapse (SLAG) wrist deformity. The peripheral tears were repaired using a zone-specific repair kit. The patients were immobilized in a munster cast, allowing elbow flexion and extension, but no pronation or supination for 4 weeks, followed by 2 to 4 weeks in a short arm cast or VersaWrist splint. All patients were reexamined independently 1 to 3 years postoperatively by a physician, therapist, and registered nurse. The results were graded according to the Mayo modified wrist score. Twenty-nine of the 45 wrists were rated excellent, 12 good, 1 fair, and 3 poor. Overall, 42 of the 45 patients (93%) rated as satisfactory and returned to sports or work activities. One patient had chronic pain, and two patients had ulnar nerve symptoms, although motion was normal in all, and their grip strength was at least 75% of the opposite hand. Arthroscopic repair of peripheral tears of the triangular fibrocartilage complex (TFCC) is a satisfactory method of repairing these injuries.     

Long-term Outcomes of Arthroscopic Debridement and Thermal Shrinkage for Isolated Partial Intercarpal Ligament Tears

A retrospective analysis was performed based on the medical records and imaging studies of 16 wrists (14 patients) with isolated partial intercarpal ligament tears (scapholunate ligament: 6 wrists, lunotriquetral ligament, 10 wrists) treated with arthroscopic debridement and thermal shrinkage. Three wrists had Geissler grade 1 tears and 13 wrists had grade 2 tears. Mean follow-up was 52.8 months. Overall pain visual analog scale scores improved significantly (P<.05) at rest and during activities of daily living and heavy manual work. Mean flexion-extension arc was 136.5°. Mean postoperative grip strength was 106 lb, which was significantly better than preoperative grip strength. Mean modified Mayo wrist score was 70 preoperatively and 94.7 postoperatively, a significant improvement. Overall functional outcomes according to the modified Mayo wrist score were rated as excellent in 13 wrists and good in 3. No patient had radiographic evidence of instability or arthritic changes. The scapholunate and lunotriquetral intervals in all patients were less than 3 mm on neutral and pronation grip radiographs. On lateral radiographs, no signs of intercalated segmental instability were seen, with a mean scapholunate angle of 55.3°.The results of this study suggest that arthroscopic debridement and thermal shrinkage provide symptomatic pain relief and prevention of intercarpal instability for a significant period of time in patients with partial intercarpal ligament tear.     

Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.     

Proximal row carpectomy: study with a minimum of ten years of follow-up

BACKGROUND: Proximal row carpectomy is an accepted motion-sparing surgical procedure for the treatment of degenerative conditions of the wrist. However, there is little information regarding the long-term clinical and radiographic results following this procedure. METHODS: Twenty-two wrists in twenty-one patients underwent proximal row carpectomy for the treatment of degenerative arthritis between 1980 and 1992. Objective and subjective function was assessed after a minimum duration of follow-up of ten years (average, fourteen years). RESULTS: There were four failures (18%) requiring fusion at an average of seven years. All four failures occurred in patients who were thirty-five years of age or less at the time of the proximal row carpectomy (p = 0.03). The wrists that did not fail had an average flexion-extension arc of 72 degrees , associated with an average grip strength of 91% of that on the contralateral side. The patients were very satisfied with fourteen of the eighteen wrists that did not fail and were satisfied with the remaining four. The patients rated nine wrists as not painful, four as mildly painful, five as moderately painful, and none as severely painful. The average Disabilities of the Arm, Shoulder and Hand score was 9 points. Radiographs revealed no loss of the radiocapitate space in three of the seventeen wrists for which radiographs were made, reduced space in seven, and complete loss of the space in seven. With the numbers available, there was no significant association between loss of joint space seen on radiographs and subjective and objective function. CONCLUSIONS: At the time of long-term follow-up, all patients older than thirty-five years of age at the time of a proximal row carpectomy had maintained a satisfactory range of motion, grip strength, and pain relief and were satisfied with the result. Caution should be exercised in performing the procedure in patients younger than thirty-five years of age. Although degeneration of the radiocapitate joint was seen radiographically in fourteen of the seventeen wrists, it did not preclude a successful clinical result.     

Madelung's deformity: quantitative radiographic comparison with normal wrists

Four measurements, ulnar tilt, lunate subsidence, lunate fossa angle and palmar carpal displacement, on wrist radiographs of 26 patients with Madelung's deformity and 48 normal subjects were compared. The range of measurements on wrists with Madelung's deformity was wider than on normal wrists, with severe deformities having very abnormal values. Some Madelung's patients had values that were within the normal range for each of the four measurements. Measurement of the lunate fossa angle demonstrated the least overlap between normal wrists and wrists of patients with Madelung's deformity with only two in the normal range. A lunate fossa angle over 29 degrees may help identify early Madelung's deformity.     

Radiographic Changes After Resection of the Distal Ulna in Patients with Rheumatoid Arthritis

Radiographic changes in the wrist after resection of the distal ulna in 61 rheumatoid patients (63 wrists) were evaluated more than five years after operation. The wrists were classified on preoperative radiographs into stable or unstable forms as defined by Simmen and Huber. Of 63 wrists, 52 were classified as stable and the remaining 11 were classified as unstable. At follow up, 50 of 52 wrists (96%) that were stable before operation had remained stable. Five of the 11 wrists that were unstable before operation had bony ankylosis or partial radiocarpal ankylosis, and in the remaining six cases there was carpal collapse. Resection of the distal ulna yields good results in stable wrists but operation is not indicated for unstable ones.     

Radiographic changes after resection of the distal ulna in patients with rheumatoid arthritis.

Radiographic changes in the wrist after resection of the distal ulna in 61 rheumatoid patients (63 wrists) were evaluated more than five years after operation. The wrists were classified on preoperative radiographs into stable or unstable forms as defined by Simmen and Huber. Of 63 wrists, 52 were classified as stable and the remaining 11 were classified as unstable. At follow up, 50 of 52 wrists (96%) that were stable before operation had remained stable. Five of the 11 wrists that were unstable before operation had bony ankylosis or partial radiocarpal ankylosis, and in the remaining six cases there was carpal collapse. Resection of the distal ulna yields good results in stable wrists but operation is not indicated for unstable ones.     

Trispherical total wrist arthroplasty in rheumatoid arthritis

Thirty-four patients, with 35 trispherical total wrist arthroplasties for treatment of rheumatoid arthritis, were evaluated at an average follow-up of 9 years (range, 5 to 11 years). The average preoperative score was 25 points inasmuch as all patients had severe pain and loss of function. The average postoperative score improved to 87 points since 30 wrists were free of pain. Twenty-eight wrists rated as a good-to-excellent result. The average arc of flexion and extension improved from 35 to 50 degrees. There were no deep infections or dislocations. Two wrists required revision, one for loosening and one for persistent pain, both requiring removal of the implant and arthrodesis. Postoperative tendon attrition occurred in six wrists, all of which had preoperative tendon ruptures necessitating tendon transfer. Radiographs showed radiolucencies in seven wrists, including seven around the metacarpal stem and one around the radial stem. The optimum results were achieved in those patients with intact extensor tendons before operation.