My 2003–2004 Sterling Bunnell Traveling Fellowship had 2 themes: (1) to learn about the care of the rheumatoid hand around the world, and (2) to serve the poor in developing nations. This travel report discusses the hand centers I visited and the surgeons who served as my hosts. My 2003–2004 Sterling Bunnell Traveling Fellowship had 2 themes: (1) to learn about the care of the rheumatoid hand around the world, and (2) to serve the poor in developing nations. This travel report discusses the hand centers I visited and the surgeons who served as my hosts.
Understanding the physical basis of hand function and deformity requires a fundamental knowledge of the biomechanics of the human digits. Learning the anatomy of the digits as well as the anatomy, function, and physiology of the muscles that control digital motion are essential in understanding the biomechanical principles that govern hand function. Applying these principles in treating hand disorders will optimize hand function and recreate hand mechanics. Understanding the physical basis of hand function and deformity requires a fundamental knowledge of the biomechanics of the human digits. Learning the anatomy of the digits as well as the anatomy, function, and physiology of the muscles that control digital motion are essential in understanding the biomechanical principles that govern hand function. Applying these principles in treating hand disorders will optimize hand function and recreate hand mechanics.
Scleroderma manifests itself in patterns ranging from localized to systemic types. Mainly the systemic type, called systemic sclerosis, involves the hand, leading to Raynaud’s phenomenon, ulcerations, arthropathies, and calcifications. Systemic sclerosis causes significant functional loss of the hand. Surgical intervention has been controversial because of anticipated wound healing problems arising from diminished blood circulation. Nevertheless, a surgical approach is indicated when conservative and pharmacologic treatment options fail. We review the literature and discuss the surgical techniques used for the most common manifestations of systemic sclerosis in the hand. Scleroderma manifests itself in patterns ranging from localized to systemic types. Mainly the systemic type, called systemic sclerosis, involves the hand, leading to Raynaud’s phenomenon, ulcerations, arthropathies, and calcifications. Systemic sclerosis causes significant functional loss of the hand. Surgical intervention has been controversial because of anticipated wound healing problems arising from diminished blood circulation. Nevertheless, a surgical approach is indicated when conservative and pharmacologic treatment options fail. We review the literature and discuss the surgical techniques used for the most common manifestations of systemic sclerosis in the hand.
Lymphedema, infection, and healing delay are among feared complications in patients undergoing upper extremity surgery after prior mastectomy and axillary dissection with or without radiation therapy. Most of these cancer patients are advised to avoid any procedure on their ipsilateral upper extremity including blood pressure monitoring, intravenous punctures, and surgery. As a result, many of these patients hesitate to undergo necessary upper extremity surgery such as arthritis surgery and even carpal tunnel release. Many hand and upper extremity surgeons believe that these precautions are unnecessarily stringent and believe that indicated upper extremity surgeries could be performed safely in these patients. We surveyed 1,200 members of The American Society for Surgery of the Hand and the 606 returned questionnaires were analyzed. More than 95% of the hand surgeons surveyed do not hesitate to perform surgery on an upper extremity in a patient after ipsilateral lymphadenectomy and/or irradiation, decreasing to 85% if there is pre-existing chronic lymphedema; 94% use a tourniquet in a routine fashion (74% use a tourniquet in the presence of existing lymphedema); 46% use a Bier block when clinically indicated (only 21% would use a Bier block in a patient with lymphedema); and 36% are comfortable using an axillary block (25% in the case of lymphedema). Thus, most of the polled surgeons would prefer to perform surgery on these patients under a general anesthetic, but still would use an extremity tourniquet for a bloodless surgical field in their routine manner. The rate of reported complications in these patients was 23% in patients with pre-existing chronic lymphedema and only 3% in patients with no lymphedema. After surgery, 46.2% of the surgeons do not undertake any additional precautions than in their routine practice with all upper extremity surgery patients. However, 53.8% would change their routine practice for such patients and these changes range from placing the surgical tourniquet on the forearm instead of the upper arm, use of perioperative prophylactic antibiotics in all patients irrespective of the type of surgery, use of postoperative compression garments, and specific postoperative hand therapy aimed at the prevention of postoperative edema. Lymphedema, infection, and healing delay are among feared complications in patients undergoing upper extremity surgery after prior mastectomy and axillary dissection with or without radiation therapy. Most of these cancer patients are advised to avoid any procedure on their ipsilateral upper extremity including blood pressure monitoring, intravenous punctures, and surgery. As a result, many of these patients hesitate to undergo necessary upper extremity surgery such as arthritis surgery and even carpal tunnel release. Many hand and upper extremity surgeons believe that these precautions are unnecessarily stringent and believe that indicated upper extremity surgeries could be performed safely in these patients. We surveyed 1,200 members of The American Society for Surgery of the Hand and the 606 returned questionnaires were analyzed. More than 95% of the hand surgeons surveyed do not hesitate to perform surgery on an upper extremity in a patient after ipsilateral lymphadenectomy and/or irradiation, decreasing to 85% if there is pre-existing chronic lymphedema; 94% use a tourniquet in a routine fashion (74% use a tourniquet in the presence of existing lymphedema); 46% use a Bier block when clinically indicated (only 21% would use a Bier block in a patient with lymphedema); and 36% are comfortable using an axillary block (25% in the case of lymphedema). Thus, most of the polled surgeons would prefer to perform surgery on these patients under a general anesthetic, but still would use an extremity tourniquet for a bloodless surgical field in their routine manner. The rate of reported complications in these patients was 23% in patients with pre-existing chronic lymphedema and only 3% in patients with no lymphedema. After surgery, 46.2% of the surgeons do not undertake any additional precautions than in their routine practice with all upper extremity surgery patients. However, 53.8% would change their routine practice for such patients and these changes range from placing the surgical tourniquet on the forearm instead of the upper arm, use of perioperative prophylactic antibiotics in all patients irrespective of the type of surgery, use of postoperative compression garments, and specific postoperative hand therapy aimed at the prevention of postoperative edema.
The rotator cuff is the most common source of shoulder pain and disability. The majority of rotator cuff injuries are caused by overuse, with the supraspinatus, a small tendon with a poor blood supply, most commonly affected. The major function of the rotator cuff is to stabilize the glenohumeral joint during active arm elevation by opposing the superior vector of the deltoid’s force. As long as the ability to actively elevate the arm is maintained, all rotator cuff injuries, including full-thickness tears, are candidates for nonsurgical management, the basis of which is strengthening of the rotator cuff and scapulothoracic stabilizers. Surgery should be considered for those patients who fail to improve after at least 3 months of nonsurgical management. Arthroscopic rotator cuff debridement without acromioplasty has short-term and long-term results equal to, if not superior to, subacromial decompression. Avoidance of iatrogenic injury to the coracoacromial arch, which is a secondary static stabilizer of the humeral head against anterosuperior migration, contributes to a low complication rate. The rotator cuff is the most common source of shoulder pain and disability. The majority of rotator cuff injuries are caused by overuse, with the supraspinatus, a small tendon with a poor blood supply, most commonly affected. The major function of the rotator cuff is to stabilize the glenohumeral joint during active arm elevation by opposing the superior vector of the deltoid’s force. As long as the ability to actively elevate the arm is maintained, all rotator cuff injuries, including full-thickness tears, are candidates for nonsurgical management, the basis of which is strengthening of the rotator cuff and scapulothoracic stabilizers. Surgery should be considered for those patients who fail to improve after at least 3 months of nonsurgical management. Arthroscopic rotator cuff debridement without acromioplasty has short-term and long-term results equal to, if not superior to, subacromial decompression. Avoidance of iatrogenic injury to the coracoacromial arch, which is a secondary static stabilizer of the humeral head against anterosuperior migration, contributes to a low complication rate.
The distal radioulnar joint (DRUJ) is highly complex in its 3-dimensional interactions resulting in wrist motion. This complicated structure is prone to injury and instability, which can be difficult to assess and treat effectively. The goal of this article is to provide a description of the anatomy, biomechanics, imaging techniques, and surgical repairs. The distal radioulnar joint (DRUJ) is highly complex in its 3-dimensional interactions resulting in wrist motion. This complicated structure is prone to injury and instability, which can be difficult to assess and treat effectively. The goal of this article is to provide a description of the anatomy, biomechanics, imaging techniques, and surgical repairs.
Areas of compression of the radial nerve with the potential causes in its course from the shoulder to distal forearm are reviewed. To understand the potential compressive sites of the radial nerve fully, it is imperative to have a good working understanding of the anatomic course and innervations of this nerve. Treatment options available to the surgeon for each area of compression are detailed along with the indications for surgical treatment. Areas of compression of the radial nerve with the potential causes in its course from the shoulder to distal forearm are reviewed. To understand the potential compressive sites of the radial nerve fully, it is imperative to have a good working understanding of the anatomic course and innervations of this nerve. Treatment options available to the surgeon for each area of compression are detailed along with the indications for surgical treatment.
Magnetic resonance imaging is a powerful tool for imaging the hand and wrist, providing differentiation between complex tissues ranging from cortical bone to the components of the triangular fibrocartilage complex. This differentiation depends on the qualities of the tissue itself and on the various techniques used in magnetic resonance imaging to acquire images. This article provides basic information regarding magnetic resonance imaging principles and equipment and shows specific examples relevant to the practice of hand surgery. Magnetic resonance imaging is a powerful tool for imaging the hand and wrist, providing differentiation between complex tissues ranging from cortical bone to the components of the triangular fibrocartilage complex. This differentiation depends on the qualities of the tissue itself and on the various techniques used in magnetic resonance imaging to acquire images. This article provides basic information regarding magnetic resonance imaging principles and equipment and shows specific examples relevant to the practice of hand surgery.
The scaphoid is the most commonly fractured carpal bone. 1 Brydie A. Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol. 2003; 76: 296-300 Crossref PubMed Scopus (157) Google Scholar These fractures are common in young, active men and rare in children or the elderly, with fractures of the distal radius predominating in both of these groups. 2 Phillips T.G. Reibach A.M. Slomiany W.P. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004; 70: 879-884 PubMed Google Scholar Scaphoid fractures are significant because of their potential complications including non-union, avascular necrosis and osteoarthritis. 1 Brydie A. Raby N. Early MRI in the management of clinical scaphoid fracture. Br J Radiol. 2003; 76: 296-300 Crossref PubMed Scopus (157) Google Scholar , 2 Phillips T.G. Reibach A.M. Slomiany W.P. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004; 70: 879-884 PubMed Google Scholar All of the potential complications of scaphoid fracture are made more likely by a delay in diagnosis and treatment.
We describe a surgical technique for the treatment of thumb carpometacarpal joint osteoarthritis that we call suture anchor arthroplasty. This technique is similar to ligament reconstruction tendon interposition arthroplasty except that the entire flexor carpi radialis tendon is secured to the thumb metacarpal base by using suture anchors instead of a bone tunnel. The use of suture anchors eliminates the need for a transosseous bone tunnel, simplifying the procedure. We describe a surgical technique for the treatment of thumb carpometacarpal joint osteoarthritis that we call suture anchor arthroplasty. This technique is similar to ligament reconstruction tendon interposition arthroplasty except that the entire flexor carpi radialis tendon is secured to the thumb metacarpal base by using suture anchors instead of a bone tunnel. The use of suture anchors eliminates the need for a transosseous bone tunnel, simplifying the procedure.
A 19-year-old man presented with a slowly growing mass in the palm of the nondominant hand. As it grew it became progressively more painful and bothersome with increasing tenderness on palpation. Initial imaging studies, including radiographs and magnetic resonance imaging (MRI), were inconclusive, suggesting that the mass might be cystic.
Trapeziometacarpal arthritis, a common and disabling condition, often is treated by open procedures involving trapeziectomy and interposition arthroplasty. A minimally invasive technique potentially could offer advantages over more common open procedures. We describe an arthroscopic technique for the treatment of trapeziometacarpal arthritis. After adequate arthroscopic debridement, interposition arthroplasty may be performed with a variety of materials. Trapeziometacarpal arthritis, a common and disabling condition, often is treated by open procedures involving trapeziectomy and interposition arthroplasty. A minimally invasive technique potentially could offer advantages over more common open procedures. We describe an arthroscopic technique for the treatment of trapeziometacarpal arthritis. After adequate arthroscopic debridement, interposition arthroplasty may be performed with a variety of materials.
Silastic metacarpophalangeal joint replacement has been used successfully to treat patients with inflammatory arthritis, particularly rheumatoid arthritis of the hand, for many years. Initially, patients can expect satisfactory relief of pain, improved alignment, movement between 30° to 60° of active flexion, and, as a consequence, improved function. The implants themselves can survive in situ for many years with a published overall survival rate of greater than 60% at 15 years or more. There are, however, a number of complications, these complications and their management are discussed further. Silastic metacarpophalangeal joint replacement has been used successfully to treat patients with inflammatory arthritis, particularly rheumatoid arthritis of the hand, for many years. Initially, patients can expect satisfactory relief of pain, improved alignment, movement between 30° to 60° of active flexion, and, as a consequence, improved function. The implants themselves can survive in situ for many years with a published overall survival rate of greater than 60% at 15 years or more. There are, however, a number of complications, these complications and their management are discussed further.
Flexor tendon reconstruction is uncommon today given the advances in flexor tendon repair and postrepair rehabilitation. Nonetheless, patients with a delay in the diagnosis of a flexor tendon laceration or patients with a failed flexor tendon repair may be candidates for reconstruction. Flexor tendon reconstruction includes flexor tenolysis, 1-stage tendon grafting, and 2-stage tendon grafting. This article reviews the surgical indications, the surgical techniques, and the reported outcomes of these procedures.
Direct muscular neurotization has limited indications: loss of the distal stump of a motor nerve or avulsion of the “neural” part of one or more muscles. These lesions cannot be repaired with conventional microsurgery techniques, and without the presented technique, the denervated muscles will remain permanently paralyzed. Despite rare failures from poor local vascular or muscular conditions, direct muscular neurotization has provided the vast majority of good results, with scores similar to those obtained with good microsurgical sutures or grafts and has been adopted by several microsurgeons.
Poorly reduced intra-articular fractures of the distal radius often result in the development of radiocarpal degenerative osteoarthritis. This complication is frequent, particularly when the fragments have healed malrotated or depressed in relation to the surrounding joint surface. Increased stress concentration in areas with a marked step enhances cartilage wear and subsequent synovitis. When symptomatic, this problem may be addressed by using a variety of noninvasive strategies including physiotherapy, resting splints, anti-inflammatory medication, and activity modification. If these methods fail, a number of surgical procedures may be indicated. This article reviews the technique, indications, and results of the different radiocarpal fusions that eventually may be used to alleviate the symptoms caused by a badly damaged radiocarpal joint. Poorly reduced intra-articular fractures of the distal radius often result in the development of radiocarpal degenerative osteoarthritis. This complication is frequent, particularly when the fragments have healed malrotated or depressed in relation to the surrounding joint surface. Increased stress concentration in areas with a marked step enhances cartilage wear and subsequent synovitis. When symptomatic, this problem may be addressed by using a variety of noninvasive strategies including physiotherapy, resting splints, anti-inflammatory medication, and activity modification. If these methods fail, a number of surgical procedures may be indicated. This article reviews the technique, indications, and results of the different radiocarpal fusions that eventually may be used to alleviate the symptoms caused by a badly damaged radiocarpal joint.
Heterotopic ossification (HO) resulting in radioulnar cross-union occurs in approximately 2% of all forearm injuries and causes significant functional impairment. Risk factors for cross-union are incompletely understood, however, injuries to the proximal forearm account for the majority of cases. Concomitant central nervous system injury greatly increases the risk for HO after forearm fracture. Although surgical excision of forearm cross-union has produced mixed results in the past, and recurrence of synostosis has been common, more recent treatment attempts have resulted in nearly full recovery of forearm rotation. Questions remain regarding the appropriate timing for excision and the advisability of adjuvant low-dose radiotherapy to prevent recurrence. It would seem that HO resulting from local trauma in the absence of other risk factors can be safely excised 6 to 12 months after injury. Adjuvant radiotherapy may be warranted in more aggressive cases of HO with a greater risk for recurrence, such as those cases involving the proximal forearm or associated with closed head injury. Heterotopic ossification (HO) resulting in radioulnar cross-union occurs in approximately 2% of all forearm injuries and causes significant functional impairment. Risk factors for cross-union are incompletely understood, however, injuries to the proximal forearm account for the majority of cases. Concomitant central nervous system injury greatly increases the risk for HO after forearm fracture. Although surgical excision of forearm cross-union has produced mixed results in the past, and recurrence of synostosis has been common, more recent treatment attempts have resulted in nearly full recovery of forearm rotation. Questions remain regarding the appropriate timing for excision and the advisability of adjuvant low-dose radiotherapy to prevent recurrence. It would seem that HO resulting from local trauma in the absence of other risk factors can be safely excised 6 to 12 months after injury. Adjuvant radiotherapy may be warranted in more aggressive cases of HO with a greater risk for recurrence, such as those cases involving the proximal forearm or associated with closed head injury.
Elbow stiffness is a common problem after trauma to the elbow. The goal of treatment should be to achieve a functional range of motion (30°–130°). Nonsurgical options are physical therapy and splinting. Surgical options depend on the degree of degenerative change in the elbow joint. With mild to moderate degenerative changes, procedures such as soft-tissue releases, debridement, and Outerbridge-Kashiwagi arthroplasties may be performed either open or arthroscopically. With more severe degenerative changes, the options are more limited depending on the age and activity level of the patient. Elbow stiffness is a common problem after trauma to the elbow. The goal of treatment should be to achieve a functional range of motion (30°–130°). Nonsurgical options are physical therapy and splinting. Surgical options depend on the degree of degenerative change in the elbow joint. With mild to moderate degenerative changes, procedures such as soft-tissue releases, debridement, and Outerbridge-Kashiwagi arthroplasties may be performed either open or arthroscopically. With more severe degenerative changes, the options are more limited depending on the age and activity level of the patient.
