Biomedical subjects
Publications and source records attributed to L K Ruby.
Closed rupture of the extensor carpi ulnaris tendon in a patient who does not have rheumatoid arthritis has not been previously reported to our knowledge. This condition should be considered in the differential diagnosis of ulnar-sided wrist pain. We report two patients with favorable response to surgical reconstruction after failure of nonoperative management.
Twenty-five patients had Russe anterior corticocancellous bone-grafting between 1973 and 1984 for twenty-six symptomatic established non-unions of the scaphoid. The mean duration of follow-up was eleven years (range, seven to eighteen years). Twenty-one (81 per cent) of the twenty-six scaphoid bones united. We developed two rating scales to evaluate the results of the operation. One scale, based on objective findings, included the radiographic appearance of the wrist, the range of motion, and strength; the other scale, based on subjective findings, comprised function, pain, perception of a decrease in performance because of limitation of motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had a malunion of the scaphoid in which the lateral intrascaphoid angle was more than 45 degrees convex dorsally between the proximal and distal poles (a so-called flexion or humpback deformity, which results in extension of the proximal fragment of the scaphoid at the radiocarpal joint) with the results in patients who had no such deformity. The lateral intrascaphoid angle was more than 45 degrees in thirteen (50 per cent) of the twenty-six wrists. Although the difference in the objective results between the wrists that had a malunion and those that did not have a malunion was highly significant (p = 0.001), there was no significant difference in the subjective results between the two groups, including satisfaction of the patient (p = 0.39). Twenty-three patients (92 per cent) returned to full-time employment and twenty-two (88 per cent), to sports activities. Twenty-three patients (92 per cent) reported that they had pronounced relief of pain and that the procedure had improved their quality of life. The presence of this deformity of the scaphoid after bone-grafting for a symptomatic non-union was not predictive of a poor long-term subjective outcome.
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Metacarpal fractures are common injuries. Most can be treated successfully by closed reduction and cast or splint immobilization. Unstable fractures, however, require internal fixation. Many such techniques are discussed. Metacarpal dislocations are more difficult to diagnose and treat than are metacarpal fractures. Careful attention to detail will help ensure a successful result.
We report a retrospective review of seven patients with chronic scapholunate dissociation treated with attempted scapholunate arthrodesis. All procedures were done between 1978 to 1983 by one surgeon. Seven patients with follow-up of nine months or greater were available for review. Follow-up for the four patients with successful operations averaged seventy-seven months. Average age was 34 years (range from 19 to 46). Only one patient demonstrated radiographic fusion. Of the remaining six patients, three had no further wrist pain. The other three operations were total failures requiring other procedures for pain relief. For all patients, flexion-extension are decreased an average of 4 degrees. Grip strength averaged 88% of the unaffected side. Lateral scapholunate angle improved from an average preoperative angle of 70 degrees to a postoperative angle of 59 degrees. We conclude that this procedure is not a predictable method to treat scapholunate dissociation.
Distal ulna resections that are done in patients with rheumatoid arthritis to alleviate pain, correct alignment, and prevent tendon rupture may contribute to distal ulnar instability. A distally based slip of the extensor carpi ulnaris tendon has been used to both stabilize the distal ulnar remnant and to prevent recurrent deformity in 26 rheumatoid wrists, with an average follow-up of 3.5 years. In all postoperative cases, the distal ulna was no longer prominent and the wrist was well aligned. The distal ulna was stabilized in 96% of the patients. Subjectively, pain was relieved in 85% and grip strength improved in 77%.
Normal functional variations of the flexor digitorum superficialis were clinically determined by use of the standard and modified superficialis flexion tests in 50 normal subjects. Forty hands of 20 cadavers were dissected to correlate the anatomic variations with the clinical findings. A flexor digitorum superficialis-independent pattern was found 58% of the time. A flexor digitorum superficialis-common pattern was found 21% of the time. A flexor digitorum superficialis-absent pattern was found 21% of the time. The right and left hands were asymmetric 26% of the time. All cadaver hands had a flexor digitorum superficialis tendon present in the palm and finger. The variability in flexor digitorum superficialis function may be explained by interconnections between the flexor digitorum superficialis of the small finger and either the flexor digitorum superficialis of the ring finger or the flexor digitorum profundus of the small finger.
Rheumatoid arthritis commonly affects the distal radioulnar joint (DRUJ). This can result in pain, instability, or tendon rupture. The goals of surgical reconstruction of the DRUJ are to relieve pain, stabilize the joint, and prevent tendon rupture. We review many of the previously described procedures and report our experience with distal ulna excision and soft tissue reconstruction with a distally based slip of extensor carpi ulnaris tendon.
The relative motion of selected carpal bones and the radius was studied using five cadaver specimens labeled with metal markers to precisely quantitate their motions. Data was obtained by means of a combination of orthoradiography, sonic digitization, and computer analysis. We conclude that the wrist functions as two carpal rows with the distal row bones relatively tightly bound to one another and the proximal row bones less so but still moving together. Therefore, we theorize that the proximal row functions as a variable geometry intercalated segment between the distal row and the radius-triangular fibrocartilage.
A 41-year-old man who was taking 60 mg of prednisone a day for dermatomyositis developed a wound dehiscence following a carpal tunnel release and flexor tenosynovectomy. Coverage of the exposed carpal contents was provided by using the abductor digiti minimi as a local transposition flap.
This study measured the diameter of the arteries at the level of the diaphysis of the proximal phalanges of the index, long, ring, and small fingers. We measured the diameter of the vessel on ten normal arteriograms and on six amputated specimens. The larger vessel was usually on the ulnar border of the index and long fingers and on the radial border of the ring and small fingers. By the Hagen-Poiseuille equation, we assume that the larger vessel has the greater flow and, therefore, represents the dominant vessel to the digit. This observation may have clinical relevance in the reimplantation and revascularization of digits.
Although the scapholunate interosseous ligament has been studied anatomically and functionally by several investigators, its exact role in wrist kinematics is still controversial. We designed and executed an experimental study with four cadaver specimens to compare various carpal motions before and after section of this ligament. Our results suggest that injury to this structure significantly changes carpal motion especially between the scaphoid and lunate.
Patients with old scaphoid nonunion have a high risk of developing wrist arthritis. Although some patients remain asymptomatic, some will have pain sufficient to seek treatment. There are several treatment options available. The authors prefer wrist arthrodesis for most of these patients.
Three patients exhibiting acute onset of proximal forearm pain and muscle weakness are reviewed. After nonoperative therapy failed, surgical exploration revealed compression of the median nerve at the level of the lacertus fibrosus. All three patients experienced complete recovery after release of the lacertus fibrosus.
Juvenile rheumatoid arthritis seldom involves the small joints of the hand. We are reporting three patients with proximal interphalangeal joint synovitis as the initial manifestation of juvenile rheumatoid arthritis. This form of presentation of the disease should be recognized so that treatment will not be unduly delayed especially for the ophthalmologic manifestations of juvenile rheumatoid arthritis.
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Multiple level amputation has been described as a contraindication to replantation. This is a case report of a patient with a double level amputation through the palm and forearm that was successfully replanted. Because of the need for multiple stages of reconstructive surgery, it was not clear until the end result that the replantation was worthwhile. The patient developed an acute respiratory distress syndrome that was probably caused by the reperfusion phenomenon. The stages of reconstruction are described in detail, as are the problems encountered. The final result included a reasonably functional hand that was far superior to the prosthetic alternative.
Ten patients with moderately to severely displaced supracondylar fractures were retrospectively reviewed. All were treated with skeletal traction with the arm positioned at the side. As a result of this treatment, eight of the ten patients had an excellent result, with restoration of both full range of motion and normal carrying angle.