Cloward technique for obtaining iliac crest bone graft in hand surgery.
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Hand↗
Biomedical subjects
J H Dobyns
Publications and source records attributed to J H Dobyns.
Arthroscopy of the wrist: anatomy and classification of carpal instability.
Carpal instability can be defined as the lack of ligamentous and skeletal support adequate to maintain a wrist stable to external forces of pinch and grasp. This instability may be static or dynamic. It has been classified as (a) carpal instability, dissociated (CID), a situation in which one or more of the ligaments are torn, and (b) carpal instability, nondissociative (CIND), a situation in which the ligaments are intact but stretched. Carpal instability can also be the result of carpal bone malalignment from various causes. Arthroscopy can be particularly useful in assessing carpal instability, however arthrography with contrast medium, fluoroscopy, and stress loading should precede this arthroscopic assessment. Arthroscopy allows visualization of the volar radiocarpal and ulnocarpal ligaments of the wrist, and the arthroscopic examination can be combined with manual manipulation of the carpal bones to detect laxity of those ligaments, to examine stability of the scapholunate and lunotriquetral interosseous ligaments, and to show instability of the distal radioulnar joint.
Arthroscopy↗
Transcarpal carpometacarpal dislocations, excluding the thumb.
During a 9-year period, we treated 13 patients with major fractures of bones of the distal carpal row creating instability of the corresponding carpometacarpal joints. Diagnosis of the injury was made early in only eight patients whose treatment consisted of open reduction, pin or screw fixation, and immobilization from 6 to 8 weeks. They showed no complications and had an excellent functional recovery. Diagnosis in five (38%) patients was delayed 1 week to 8 months after the accident. At initial presentation, symptoms included pain, loss of grip strength, and mild limitation of finger motion. In three patients an acute carpal tunnel syndrome developed a few days after the accident. Two had established nonunions of the capitate and the hamate. Treatment consisted of open reduction, bone grafting, fixation with multiple pins, and immobilization until fracture consolidation. Results in this group were good in one, moderate in three, and poor in one.
Accidents, Traffic↗
Gymnast's wrist.
The wrist is a frequent site of symptoms and injury in the gymnast, both acute and chronic. The chronic injuries are due to repetitive loading of the musculoskeletal system, and their incidence rises as participation and level of competition rises. More attention needs to be directed toward prevention, but many of these injuries seem to be inherent to the sport as it transforms the upper extremities into weight-bearing limbs. Evaluation and recognition of wrist injuries in the gymnast will allow appropriate management for these patients; however, the compulsive and intense nature of many gymnasts can lead to recurrent or new injury and continued wrist symptoms. Much more sophisticated and detailed examination of the gymnast's wrist should be done before onset of training, before increase of intensity of training, before competition, and with the onset of any symptoms, including observed guarding. In addition, pretraining and annual follow-up wrist radiographs should be considered for the skeletally immature gymnast. Follow-up evaluation after skeletal maturity and retirement from active participation is needed to elucidate the long-term effect of gymnastics on the wrist.
Chronic Disease↗
Helping parents to decide what is best for their child.
Helping parents to decide what is best for their child is a necessary portion of medical management for the injured, anomalous, or sick child. It involves collecting information about, consideration of, and giving advice concerning much more than medical details. Certain steps are suggested in offering this help: (1) obtaining comprehensive medical, socioeconomic, and psychologic information; (2) packaging this information to inform fully and satisfy the parents/surrogates of the child; (3) confirming the family's informed participation in the treatment decision; and (4) reinforcing that decision with a very supportive and communicative perioperative period.
Child↗
Traumatic axial dislocations of the carpus.
Among 1140 patients treated in the last 16 years for any type of carpal fracture, dislocation, or subluxation, 16 (1.4%) patients seen with a traumatic axial disruption of both the carpus and metacarpus were identified. Most of these were crush or blast injuries. According to the direction of instability, the cases were classified into three groups: axial-ulnar disruptions (4 patients), axial-radial disruptions (11 patients), and combined axial-radial-ulnar disruption (1 patient). Treatment consisted of open reduction and percutaneous Kirschner-wire fixation in most cases. The results were less optimistic than suggested in the literature. An average follow-up of 61 months showed that prognosis was determined more by the associated soft tissue injuries than by the carpal derangement itself. Early management of both the skeletal and soft tissue components of the injury seems most effective.
Adolescent↗
Primary malignant bone tumors of the hand.
Malignant bone tumors of the hand are rare and few centers have extensive experience in the care of patients with these lesions. Eighteen patients with 22 lesions were evaluated at our institution. There were nine chondrosarcomas, four hemangioendothelial sarcomas, two cases each of osteosarcoma and fibrosarcoma, and a single case of Ewing's tumor. The average age of the patients was 39 years. Ten lesions each were located in the metacarpals and phalanges, with two lesions in the carpus. There were nine local recurrences, which appeared at an average of 24.5 months (range, 3 to 74 months). Curettage procedures resulted in the highest rate of local recurrence (85%). Three patients died of metastatic disease. Surgical control of these lesions requires careful preoperative planning and wide surgical margins. Regular oncologic follow-up is necessary.
Adolescent↗
Congenital anomalies of the upper extremity.
This article has reviewed some of the current methods of management of congenital problems in the upper extremity. Not all problems have been included in this review but some of the landmark advances in this field have been considered. The management of congenital anomalies may change significantly in the future.
Arm↗
Lipofibromatous hamartoma of nerve.
Seventeen cases of lipofibromatous hamartoma of nerve (14 with histologic confirmation) were treated between 1935 and 1985. One patient had bilateral involvement. Fourteen lesions were located in the upper extremity and four in the lower extremity. Twelve of the 18 lesions were associated with combined soft tissue and skeletal enlargement, or true macrodactyly. Three other lesions had soft tissue enlargement other than that noted intraneurally. Three patients were treated with carpal tunnel release alone and 14 with combined procedures to decrease the size of the affected part. Sensibility in the affected part often appeared unrelated to removal or preservation of hamartomatous nerve tissue. Complications related to nerve surgery included recurrence of carpal tunnel syndrome in one patient, recurrent soft tissue mass in one patient, and painful calcification of the involved tissues 20 years postoperatively in one patient.
Adolescent↗
Failed distal ulna resections.
Twenty patients with complaints of pain and limitation of activities for more than 1 year after ulnar head resection (Darrach) were studied. Their ages ranged from 18 to 60 years (mean, 38 years). The initial indications for operation were posttraumatic derangement in 18 patients, radial growth anomaly in 1, and a lesion of the ulna in 1. Follow-up ranged from 29 to 135 months (mean, 61 months). The patients had an average of 2.2 additional operations, with up to seven procedures per patient. Radiographs were compared with those from an equal number of successful Darrach resections chosen randomly, and no significant differences were noted. All 20 patients continue to have difficulties despite several years of treatment. The Darrach resection can result in serious disability, especially in the younger patient and the patient with lax ligaments. Reoperation on these patients is rarely successful.
Adolescent↗
Scaphoid nonunion: role of anterior interpositional bone grafts.
Twenty-one cases of unstable fractures of the scaphoid were treated by open reduction, length restoration by interpositional anterior wedge grafting, and fixation with a Herbert screw to obtain union and restore carpal stability. There was primary union in 15 (71%) of 21 patients. Two failed cases were treated with a second anterior wedge graft and Herbert screw fixation; overall rate of union was 81%. Nonunions were related to improper screw placement, failure of compression at the nonunion, bone-graft resorption, or persistent avascular necrosis. In the united scaphoids, carpal instability was corrected, with improvement in the scapholunate angle (65 degrees to 54 degrees) and capitolunate angulations (35 degrees to 15 degrees). Scaphoid malalignment associated with nonunion was improved on biplanar tomographic measurement of the scaphoid angles.
Adolescent↗
Epithelioid sarcoma. An analysis of fifty-one cases.
Analysis of the cases of fifty-one consecutive patients who had an epithelioid sarcoma revealed the five-year rate of survival to be approximately 70 per cent and the ten-year rate, approximately 50 per cent. The five-year rate of survival was about 40 per cent for the male patients and about 80 per cent for the female patients. If the primary tumor was more than three centimeters in diameter or was deeply situated, the patients had a reduced life-span, as did the patients in whom the tumor was focally necrotic. More male than female patients had necrosis of the tumor, as seen on the pathological specimens. No significant difference in life-span was noted among the patients in whom the resection had a marginal, wide, or radical surgical margin. The data indicate that wide or radical resection should be done as soon as epithelioid sarcoma is diagnosed.
Adolescent↗
Carpal tunnel release in patients with diffuse peripheral neuropathy.
Sixty carpal tunnel decompressions were performed in 44 patients with combined carpal tunnel syndrome and peripheral neuropathy. Symptomatic improvement was obtained in 92% of the patients and complete relief of symptoms in 72%. We conclude that peripheral neuropathy is not a contraindication to carpal tunnel decompression.
Adult↗
Role of the physician in workers' compensation injuries.
A variety of physician involvement is possible in the workers' compensation process. The three stages of most workers' compensation injuries are as follows: (1) initial and sequential treatment of the injury, (2) rehabilitation, and (3) control of the return to work agenda. Each of these three stages should be under the control of a physician, preferably the same physician. Only with close control of treatment and close monitoring of rehabilitation and work conditions can optimum results be obtained and maintained.
Arm Injuries↗
Posttraumatic ulnar translation of the carpus.
Ulnar translation of the carpus is a rare posttraumatic carpal instability pattern, in which the entire carpus is displaced ulnarward on the radioulnar surface. No previous formal reports of this problem have been located although it has been described in general discussions of wrist instability. Seven men and one woman were diagnosed with this condition although the diagnosis was delayed from 2 to 23 months, an average of 7.3 months. Three patients were treated surgically before diagnosis; the other five patients were treated conservatively before diagnosis. At the time of definitive diagnosis the radiographs showed an ulnar translation of the carpus, which was quantified on the radiographs in all eight patients by the method of Chamay. Four patients had an attempt to repair the radiolunate and radiocapitate ligaments. One patient had a ligamentous augmentation of the radiocapitate ligament complex. Two patients had ligamentous repairs of a scapholunate dissociation; one of these had simultaneous radiocarpal ligamentous augmentation. The eighth patient had a radiolunate arthrodesis. Follow-up averaged 32 months. Three patients had formal wrist arthrodeses at 10, 13, and 26 months after initial ligamentous repair, which were considered treatment failures. In the remaining five patients, four had partial recurrent ulnar shift, which was seen radiographically. Of these, three patients rated the result as good, with near normal strength and returned to full activities while two obtained fair results, with minimal pain but decreased range of motion and decreased strength. One patient has shown progressive degenerative radiocarpal changes and may become a candidate for a limited or formal wrist arthrodesis.
Adult↗
Ulnar variance in carpal instability.
Ulnar variance was measured in wrist conditions of patients with carpal instability and compared to values obtained from the assessment of normal wrist x-ray films. The results showed a significantly greater amount of negative ulnar variance in patients with scapholunate dissociations than in normal controls (t-test, p less than 0.0005; chi-square test, p less than 0.02). Ulnar variance in lunotriquetral dissociations and old scapholunate dissociations with arthrosis did not differ significantly from controls (p greater than 0.6). Posttraumatic scapholunate dissociations do correlate with negative ulnar variance.
Carpal Bones↗
Difficult wrist fractures. Perilunate fracture-dislocations of the wrist.
Perilunate dislocations of the wrist have a common pathway of disruption that occurs from extensive dorsiflexion injuries. Open reduction and internal fixation of these injuries is required to provide accurate alignment and the option for ligament repair. Both dorsal and palmar surgical incisions may be indicated. Associated injuries to the median nerve must be recognized. Treatment includes scaphoid and radial styloid stabilization with multiple K-wires or internal compression screw (Herbert or Association for the Study of Internal Fixation [ASIF] screws). In these injuries, the lunate must be reduced first and stabilized. The scaphoid proximal segment follows the lunate unless the scapholunate (SL) ligament is torn. The distal scaphoid fragment, capitate, and triquetrum are reduced and aligned with the lunate and need to be held with K-wires. Ligament repair and augmentation may be necessary at both scapholunate and lunotriquetal areas if there has been serious ligament injury. Palmar ligament repair is often required, and we recommend a palmar exploration in most patients along with release of the median nerve. Surgical treatment results of perilunate fracture-dislocations of the wrist appear better than conservative treatment methods, but complications following both indicate the need for improved internal fixation and fracture-dislocation realignment. These fractures are a real challenge to the treating surgeon who must use patience, precise surgical techniques, and careful roentgenographic study (including tomograms and traction views) to assure the best result.
Adolescent↗
Giant cell reaction (giant cell reparative granuloma) of the small bones of the hands and feet.
Giant cell reactions (giant cell reparative granulomas) are uncommon lesions that predominantly involve the small bones of the hands and feet. In 1980, only 13 cases of this entity had been described. Three patients with similar giant cell reactions were identified from the Mayo Clinic files, and an additional 27 patients were collected from the consultation files of one of the authors. Clinical information and follow-up data for these 30 patients suggest that the biologic behavior and, therefore, treatment of giant cell reactions differ from those of true giant cell tumors in the small bones of the hands and feet.
Adolescent↗