Biomedical subjects
Publications and source records attributed to C P Melone.
Two cases of pisiform-hamate coalition with compression of the ulnar nerve at the wrist are reported. Pisiform-hamate coalition is a rare entity previously thought to be exclusive to West Africans and without clinical significance. These cases occurred in white patients. This is the first description of a carpal coalition resulting in ulnar neuropathy at the wrist.
The surgical pathology in 42 cases of traumatic triangular fibrocartilage complex (TFCC) disruption comprised a spectrum of injury resulting in five basic stages of increasingly severe ulnar wrist instability. In all cases, detachment of the articular disk from its ulnar insertion was the principal cause of distal radioulnar joint instability; in 28 (67%), concomitant injury to the adjacent extensor carpi ulnaris sheath, the ulnocarpal ligaments, or the peritriquetral ligaments compounded the instability. Thus, rather than an isolated event, peripheral disruption of the disk often proved the major constituent of multicomponent lesions--lesions consistently suitable for repair. In this series of destabilizing TFCC disruption requiring operative treatment, awareness that some injuries selectively affect the articular disk, whereas others compromise wider zones of wrist anatomy, was essential to successful surgery.
We conclude from this study that distal ulna resection coupled with stabilization by ECU tenodesis is a highly useful technique with a reproducibly successful outcome for DRUJ destruction resulting from rheumatoid arthritis. In this series, like those noted previously, alleviation of pain, preservation of wrist mobility, prevention of tendon rupture, and improved function have been consistently observed. Moreover, with adjunctive dorsal synovectomy this combined procedure has proved applicable to cases demonstrating not only mild but also moderate stages of radiocarpal disease, thereby avoiding the more extensive and less desirable surgical alternatives of complete wrist arthrodesis or total wrist arthroplasty. Recognizably, the long-term benefit of this surgery depends on maintaining stability of both the reconstructed radioulnar joint and the synovectomized radiocarpal joint. Although the data reported herein strongly support the efficacy of the tenodesis in preserving distal ulna stability and similarly indicate a favorable influence on maintenance of radiocarpal architecture, one must be cognizant that progressive radiocarpal deterioration is a characteristic, albeit somewhat unpredictable, manifestation of the chronic rheumatoid process, and is the principal factor apt to compromise an initially satisfactory result. In such cases demonstrating excessive carpal malalignment preoperatively and for those with an unremitting postoperative course of ulnar translocation or volar subluxation, additional radiocarpal stabilization, preferably by arthrodesis, is essential to salvage the benefits of distal ulna resection and ECU tenodesis.
Magnetic resonance (MR) imaging of the wrist was performed in 35 patients with specific complaints of pain and soft-tissue swelling in the medial side of the wrist. Twenty of the 35 subsequently underwent surgery. In 14 of the patients who underwent surgery, a diagnosis of triangular fibrocartilage (TFC) tear was made at MR imaging; in 13 of the 14 the tear was confirmed by surgical findings. In the six patients with an MR diagnosis of an intact TFC, surgical findings confirmed the diagnosis. These patients were operated on for an abnormality in the vicinity of the TFC (avascular necrosis, ganglion cyst, xanthoma). On the basis of findings from the 20 patients with surgical correlation, the accuracy of MR imaging in the detection of TFC tears was 95%. MR imaging is a valuable noninvasive method in the study of pathologic conditions of the TFC.
A classification of distal radial articular fractures is described, based on observations of consistent patterns of fracture fragmentation and displacement. The classification categorizes articular fractures into four types, with the medial complex assuming a pivotal position as the cornerstone of both the radiocarpal and distal radioulnar joints. The purpose of this classification is four-fold: (1) to afford identification and an understanding of the displacement characteristics of the major fracture components, (2) to provide practical and rational guidelines for the management of these injuries based on specific fracture patterns, (3) to emphasize the frequency of concurrent soft tissue and other skeletal injuries associated with the more severe types of articular disruption, and (4) to serve as a prognostic gauge for the varied spectrum of distal radius articular injury. Optimal management of distal radius fractures necessitates the differentiation of articular from extra-articular fractures as well as prompt detection of unstable injuries. While the majority of unstable fractures can be successfully managed by closed methods, a substantial and increasing number require open treatment for restoration of articular congruity as well as repair of concomitant soft tissue and skeletal injuries. In all cases, precise reduction of the key medial fragments is essential to maximum recovery.
The historic development of prosthetic total elbow arthroplasty is traced and results of constrained, semiconstrained, and nonconstrained designs reported. The authors' personal experience with the semiconstrained total elbow replacement, surgical indications with an emphasis on careful patient selection, and highlights of operative technique are discussed. Pain, instability, ankylosis, and arthritic degeneration of the elbow have inspired many surgical attempts to improve function and relieve pain. The most sophisticated surgical options now include total elbow replacement. This paper reviews the development of total elbow arthroplasty and assesses the experience with semiconstrained total elbow replacements performed at the New York University Medical Center over the last eight years.
Rational guidelines are provided for the early operative treatment of the severely injured wrist. The prominent anatomic features of the wrist as well as clinically relevant kinematics and pathomechanics are reviewed. Diagnostic and operative techniques applicable to acute injury are described. The authors point out that while the concept of prompt restoration of normal anatomic relationships in the acutely injured wrist may appear to be simple, the clinical application of the concept is quite difficult. However, an accurate diagnosis along with early meticulous surgical intervention will generally lead to a good result.
Disabling trapeziometacarpal osteoarthritis is often associated with other skeletal or soft tissue pathology that necessitates simultaneous treatment. In this study of 100 trapezium arthroplasties, 65% of the patients required at least one concurrent operative procedure and, overall, 75% have received treatment for related problems before, during, or after the arthroplasty. In order of frequency, scaphotrapezial arthritis, carpal tunnel syndrome, hyperextension deformity of the thumb metacarpophalangeal joint, trigger digits, and tenosynovitis of the wrist have been the most prevalent concomitant conditions requiring surgery. Awareness that trapeziometacarpal arthritis is frequently the focal site of a widespread inflammatory process involving other structures of the hand--termed herein the "basal joint pain syndrome"--is essential to optimal management of patients with pain at the base of the thumb.
Rational use of rigid fixation in hand surgery requires awareness of the advantages as well as the potential pitfalls of this relatively complex method of fracture management. A rational decision also necessitates familiarity with closed techniques of internal fixation which, in most cases, provide superior alternatives for the phalanges and metacarpals. The optimal application of screws, plates, and tension-band wires to small bone fractures can be ascertained only by critical assessment of large series of cases employing these devices and comparisons with similar series using other techniques of internal fixation. Nonetheless, rigid fixation is the logical choice for treatment of unstable fractures when other methods are predictably less effective. Injuries most suitable for screw or plate fixation include displaced phalangeal condylar fractures, irreducible oblique phalangeal fractures, irreducible transverse metacarpal fractures, disabling malunions, and nonunions requiring multiple adjunctive procedures. For selective fractures, especially those with established deformity or serious joint contractures, the capacity of rigid fixation to effect immediate skeletal stability and facilitate early digital motion can considerably enhance recovery. Complications are minimized by precision--in case selection and surgical techniques.
Injuries to the small joints of the hand are prevalent in both professional and amateur athletes. The majority of these injuries result in partial tears of the capsular support structures and can be successfully treated by precise splinting followed by thorough rehabilitation. In contrast, optimal management of complex dislocations or complete ligament ruptures causing serious joint instability necessitates operative intervention to secure reduction and facilitate ligament healing. There is an enviable satisfaction in observing a recovered athlete perform to the limits of his or her abilities, unimpaired by any residual disability or deformity. This goal can only be achieved by the timely institution of skillful management.
Fifteen patients with severely displaced Type 4 articular fractures of the distal radius required open treatment for the reduction and fixation of disrupted articular surfaces and for the repair of associated nerve, tendon, or arterial injuries. These patients were predominantly young men whose wrists had been exposed to violent compression forces. Five cases were rated excellent, nine good, and one fair according to the McBride and Lidström systems of evaluation. In this study, distal radial fractures with wide displacement or rotation of the articular surfaces were treated by prompt and precise repair of skeletal and soft tissue damage.
Hand injuries account for an increasing incidence of emergency room visits, both for purposes of diagnosis and treatment. Patients are also expressing a growing reluctance toward hospitalization for procedures that are now performed with precision in the office or same day surgical unit. These two factors are largely responsible for an increasing reliance on regional techniques to provide optimal anesthesia. The safety, versatility, ease of administration, and consistent success of regional anesthesia validate its frequent use.
The primary care physician has a profound influence on the prevention of deformity and disability resulting from fingernail injuries. Prompt recognition and precise repair of the disrupted nailbed consistently result in successful nail restoration. For injuries with a substantial subungual hematoma or a displaced phalangeal fracture, optimal treatment requires removal of the nailplate, reduction of the fracture, and meticulous repair of the nailbed. Even with severely fragmented or avulsion injuries, the results of an accurate primary repair are generally far superior to those of corrective surgery for established fingernail deformities. Skillful primary repair is the best method of managing the vast majority of fingernail injuries.
Prompt recognition of the magnitude of articular damage is essential for optimal management of digital joint injuries. Basic to this concept is the need to differentiate injuries that can be successfully treated by closed techniques from those that require surgery. Following an accurate restoration of the damaged joint, recovery of function depends on careful immobilization in a protective position and, whenever possible, early joint mobilization. Precise primary care is the key to the prevention of disabling joint contractures.