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Biomedical subjects

W B Kleinman

Publications and source records attributed to W B Kleinman.

At least 19 recordsLinked to original sources
PubMed1999

Occult scapholunate ganglion: a cause of dorsal radial wrist pain.

There are multiple causes for chronic dorsal wrist pain over the scapholunate ligament, including occult dorsal carpal ganglion cyst, scaphoid impaction syndrome, dorsal carpal capsulitis, distal posterior interosseous nerve syndrome, and dynamic scapholunate ligament instability. Patients with such pain often have normal x-rays. A retrospective study of 21 patients undergoing surgical exploration for chronic dorsal radial wrist pain who had no palpable cyst and normal x-rays revealed that 18 of the patients had occult scapholunate ganglion cysts or myxomatous degeneration within the scapholunate ligament. All had failed long-term conservative management. Surgery involved an approach through Langer's lines, resection of a large triangular portion of the capsule between the dorsal intercarpal and radiotriquetral ligaments, and tangential debridement of the area of myxoid degeneration proximal to the distal 2 to 3 mm of dorsal scapholunate interosseous ligament. None of the patients had scapholunate instability or scaphoid impacting syndrome. Of the 18 patients with histologically confirmed myxomatous changes in the scapholunate ligament, 16 had an excellent outcome as defined by rigorous criteria; 1 had a good outcome. There was 1 patient with a poor result. A compelling argument is made for surgical exploration of the scapholunate joint in patients with persistent dorsal radial wrist pain and scapholunate point tenderness.

Adolescent↗
PubMed1999

Cubital tunnel syndrome: anterior transposition as a logical approach to complete nerve decompression.

In it's native position, deep to Osborne's ligament, within the retrocondylar groove of the elbow, the ulnar nerve courses with a significant lever distance posterior to the elbow axis of rotation. In this position, flexion of the elbow places longitudinal traction and local compression forces on the nerve. This biomechanical consideration, as well as variations in anatomy, may potentially contribute to a decrease in the nerve's microcirculation and partial pressure of oxygen, leading to cubital tunnel syndrome. Anterior transposition of the ulnar nerve at the elbow for cubital tunnel syndrome will eliminate natural as well as pathological traction and compression forces; the procedure relieves the nerve of potential microcirculation compromise. Risks of mobilizing the nerve for transposition, however, include iatrogenic ischemia from segmental separation of the nerve from its mesentery-like extrinsic blood supply. Intrinsic interstitial "step-ladder" vessels within the substance of the ulnar nerve allow it to be separated from its extrinsic circulation safely, making anterior transposition a logical and reasonable choice for cubital tunnel syndrome requiring operative intervention.

Cubital Tunnel Syndrome↗
PubMed1998

The distal radioulnar joint capsule: clinical anatomy and role in posttraumatic limitation of forearm rotation.

Posttraumatic limitation of forearm rotation can be the result of pathology at any location along the forearm axis. Scar contracture of the distal radioulnar joint (DRUJ) capsule, independent of the triangular fibrocartilage complex (TFCC), is one of the sources that may influence the pronosupination arc. We dissected the wrists of 8 fresh-frozen cadaver specimens to characterize the precise anatomy, relationships, and dynamic characteristics of the entire DRUJ capsule. Additionally, we performed surgical DRUJ capsulectomy in 9 patients with recalcitrant limited forearm pronosupination that was unattributable to dysfunction at any other anatomic forearm location. We conclude that (1) the DRUJ capsule is a defined entity, separate from the triangular fibrocartilage, that is highly specialized to accommodate the distal ulna in forearm rotation; (2) in patients who have restored osseous anatomy after trauma, but have failed to regain pronosupination after maximal rehabilitation, the DRUJ capsule can be identified as the source of the limitation; and (3) DRUJ capsulectomy can markedly improve the arc of forearm rotation in carefully selected patients.

Biomechanical Phenomena↗
PubMed1998

Disorders of the forearm axis.

Forearm pronosupination is a complex, integrated activity that demands specialized function of all structures between the elbow and wrist. This article describes the forearm axis as a comprehensive concept to unify these relationships. The anatomy and biomechanics of the forearm axis are reviewed. Pathologies that affect the entire axis are summarized.

Biomechanical Phenomena↗
PubMed1996

Vitamin B6 (pyridoxine) therapy for carpal tunnel syndrome.

The literature at this time does not give convincing evidence for use of pyridoxine as the sole treatment when confronted with a patient with idiopathic CTS. It may be of value as an adjunct in conservative therapy through altered perception of pain and increased pain threshold. For patients not responsive to conservative therapy, surgical decompression of the carpal canal is the treatment of choice.

Carpal Tunnel Syndrome↗
PubMed1996

Anterior intramuscular transposition of the ulnar nerve.

The surgical management of cubital tunnel syndrome is well documented in the literature. Anterior intramuscular transposition of the ulnar nerve is indicated for chronic cubital tunnel syndrome with symptoms refractory to conservative therapy. Prompt diagnosis is essential to yield excellent results. Extreme care must be exercised in the performance of anterior intramuscular transposition. The surgeon must know the details of medial epicondylar anatomy and pathophysiology, as well as all possible sites of potential nerve compression. The placement of the transposed nerve in an intramuscular bed requires that all fibrous septae are resected from the shallow trough created for the nerve to avoid scar formation. Postoperatively, the arm is immobilized for 3 weeks, after which range-of-motion exercises are begun. By the eighth postoperative week, most patients are able to resume their regular activities, including manual labor. Recurrence or persistence of symptoms postoperatively typically is traced to an inadequate decompression of the nerve. Common sites of persistent ulnar nerve compression include (1) the medial intermuscular septum, (2) the arcade of Struthers, (3) fibrous bands immediately proximal or distal to the cubital tunnel, (4) persistence or kinking at the arcuate ligament of Osborne, (5) Spinner's ligament or other fascial slings, and (6) incomplete anterior transposition. Anterior intramuscular transposition of the ulnar nerve is attractive for its relative ease of dissection, simplicity, reliability, and low morbidity. Transposition of the nerve into a shallow muscular trough deep only to the flexor-pronator fascia is a logical, effective, and consistently reliable method of treating cubital tunnel syndrome refractory to conservative management.

Humans↗
PubMed1995

Salvage of the failed Darrach procedure.

Six patients (5 post-traumatic, 1 rheumatoid) underwent a three-component reconstruction for correction of dorsal instability and radioulnar impingement following failure of a Darrach resection of the entire distal end of the ulna. The technique was devised to prevent simultaneous coronal and sagittal instability. The procedure used longitudinal intramedullary tenodesis of the extensor carpi ulnaris tendon, dorsal transfer of the pronator quadratus through the interosseous space, and temporary percutaneous pinning to maintain corrected distal radioulnar relationship. The were evaluated for 11 to 39 months (average, 20 months) following reconstruction. The preoperative wrist extension-flexion arc was preserved following surgery; there was a minimal loss of radial and ulnar deviation. The arc of forearm rotation increased 24 degrees to a range equal to 95% of the rotational arc of the opposite, unoperated wrist. Postoperative grip strength improved to an average value of 65 lb., two and one half times the preoperative value, representing 80% of the value for the opposite extremity. Four patients were able to return to their previous employment. All patients achieved pain-free forearm rotation and relief of their preoperative complaints of painful mechanical popping, clicking, and catching.

Adult↗
PubMed1994

Revision ulnar neuroplasty.

Revision ulnar neuroplasty should be performed in cases of recurrence or persistence of symptoms or signs of ulnar entrapment neuropathy at the elbow following cubital tunnel release, with or without previous epicondylectomy or anterior transposition. Most cases of recurrence or persistence of symptoms reported in the literature could be traced at reoperation to failure of the initial treating surgeon to decompress the nerve adequately at all potential sites of compression. Included in this assessment were those cases of unwarranted postoperative nerve tension in elbow flexion, the result of maintaining the neurolysed nerve in its retrocondylar position. The most probable sites of persistent compression include (1) the medial intermuscular septum, (2) the arcade of Struthers, (3) fibrous bands at the entrance or exit of the cubital tunnel, (4) persistence or kinking at Osborne's arcuate ligament, (5) fascial slings, and (6) incomplete anterior transposition. Severe perineural fibrous compromising intraneural microcirculation in an inadequate, poorly vascularized bed is also a frequent finding, particularly in cases in which patients have undergone submuscular transposition. When a revision ulnar neuroplasty is performed at the elbow, a formal neurolysis and epineurotomy should be performed under loupe magnification. Once all potentially compressing structures have been freed and the nerve completely relaxed, it should be placed within a muscle sleeve of the flexorpronator mass, created by a 5-mm trough deep to the anterior flexor-pronator fascia. The overlying fascia is repaired securely without any direct contact with the nerve.

Elbow Joint↗
PubMed1993

Effects of the fasciocutaneous radial forearm flap on vascularity of the hand.

Twelve randomly selected fasciocutaneous radial forearm flaps underwent bilateral vascular analysis an average of 26 months following surgery. Digital temperature comparisons revealed an average 2.5% (0.8 degree C) decrease following use of the radial forearm flap. Doppler flow studies performed to determine the digital/brachial pressure indices revealed no significant difference between the donor (1.06) and control (1.08) extremities; however, Doppler pulse-volume recordings performed after cold stress testing revealed an 18% delay in reconstitution of normothermia in the radial forearm flap group compared to controls. Only two patients reported transient mild symptoms of cold intolerance, which resolved over time.

Adult↗
PubMed1991

Tendon suspension sling arthroplasty for thumb trapeziometacarpal arthritis.

Forty consecutive tendon suspension sling arthroplasties for relief of pantrapezial osteoarthritis in 38 patients were reviewed. The procedure consists of excision of the trapezium and reconstitution of the tethering action of the first intermetacarpal and the palmar oblique carpometacarpal ligaments; 50% of the distally based flexor carpi radialis tendon is used. A double figure-eight sling suspends the first metacarpal securely, followed by distal advancement of the abductor pollicis longus to tighten the sling and palmarly abduct the thumb ray. The technique resulted in relief of pain, preservation of strength, maintenance of a normally contoured first web space, and functional carpometacarpal range of motion. Procedures were performed over a 4-year period (1986 to 1990), with an average follow-up of 21 months. At final follow-up, 85% of the patients had minimal symptoms; key pinch and grip strengths measured 76% and 81% of the contralateral uninvolved side, respectively. The logic of the mechanical design of the procedure and encouraging subjective and objective follow-up at 4 years make the technique of tendon suspension sling arthroplasty an attractive alternative to existing procedures for the surgical management of recalcitrant and disabling osteoarthritis of the basilar thumb joint.

Adult↗
PubMed1991

Management of chronic peripheral tears of the triangular fibrocartilage complex.

Injury to the triangular fibrocartilage is recognized with increasing frequency as a major source of pain on the ulnar side of the wrist. Traumatic separation of the well-vascularized medial insertion of the triangular fibrocartilage complex at the fovea of the ulnar styloid is less common than attritional perforation of the central hypovascular articular disc. Thirteen patients with traumatic separation of the triangular fibrocartilage complex from its peripheral origin (eleven with documented single-episode antecedent trauma) had anatomic reconstitution by surgical reattachment to the ulna. After postoperative rehabilitation, return to essentially normal painless activities was reached in eight of eleven patients with follow-up greater than one year. Two of the three unsatisfactory results responded well to subsequent surgery (distal ulna resection; ulnar shortening osteotomy); one patient has been unable to return to competitive gymnastics and seeks no further treatment.

Adult↗
PubMed1990

Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic scapho-lunate instability: a 10-year perspective on pitfalls and complications.

Goals of reducing wrist pain, allowing a stable active wrist range of motion, and retarding degenerative changes make arthrodesis of the scapho-trapezio-trapezoid joint a popular treatment for chronic static and dynamic scapho-lunate instability; however, pitfalls and complications have not been well studied. Forty-seven wrists in 46 patients over a 10-year period revealed a complication rate of 52%. Failure to attain perfect scaphoid reduction consistently resulted in persistent incapacitating pain. Radial styloid-scaphoid impingement, observed after "successful" limited wrist fusion, was effectively treated by simple styloidectomy. Carpal osteomyelitis, lunate avascular necrosis, pin-tract infection, progressive medial carpal translation, and intractable pain without arthrosis complete the spectrum of complications managed in this series. Careful preoperative patient screening and attention to detailed recommendations will assist surgeons in avoiding the many potential problems associated with this procedure.

Arthrodesis↗
PubMed1990

Management of thumb hypoplasia.

This chapter emphasizes the dilemma of salvage and reconstruction of the congenitally aplastic or hypoplastic thumb without normal cerebrocortical representation for prehensile grasp and pinch. The philosophy of reconstruction of the congenitally anomalous thumb is clearly divergent from thumb reconstruction following trauma. It is difficult to advise parents who seek surgical correction of the severely deficient thumb ray that amputation is the procedure of choice, to be followed by transfer of an otherwise normal digit to become a functional thumb unit. The psychological impact of these recommendations may be devastating to parents. Informed understanding of the likely progressive development of index-middle finger scissoring, pronation of the index ray with spontaneous broadening of the pulp, and the deteriorating use of an existing hypoplastic thumb may make the decision for ablation easier for parents. It is critical that these decisions be made through careful education and understanding, considering always the overall grasp-and-pinch capability of the hand as a whole. Reconstruction of the aplastic or hypoplastic thumb is an exciting and challenging area of hand surgery. The rewards are improvement in grasp and pinch either by functional integration of the reconstructed part, or by complete replacement of the deficient thumb by tissue from adjacent or distant donor sites. Success is measured not only in terms of cosmetic appearance, but as enhanced capacity of the child's hand in all activities of daily living (Fig. 39A and B).

Child↗
PubMed1989

Long-term study of chronic scapho-lunate instability treated by scapho-trapezio-trapezoid arthrodesis.

The effect of scapho-trapezio-trapezoid arthrodesis on wrist kinematics was studied in 25 patients with chronic static scapho-lunate instability and in 16 patients with dynamic instability, with follow-up ranging from 24 to 101 months (average, 56 months). Postoperative planar and cineradiographic examination in patients returning to heavy labor reveal an absence of carpal shift-influence of the scaphoid proximal pole on the lunate-triquetral unit in ulnar deviation. Scapholunate diastasis present before operation persists in ulnar deviation as the STT fusion mass, capitate, and hamate rotate with the hand into ulnar deviation; the lunate-triquetral unit is not physiologically "pulled" radially into the lunate fossa of the radius. Triquetro-hamate mechanics remain normal as active engagement along the helicoidal triquetro-hamate interface initiates proximal row dorsiflexion. Clinical postarthrodesis wrist motion is a combination of intercarpal and radiocarpal mechanics, with energy in the flexion and extension arc dissipated through the scapho-lunate interface. The paucity of arthritic changes after up to 101 months after surgery is based on the kinematic changes presented in these data.

Adolescent↗
PubMed1989

Anterior intramuscular transposition of the ulnar nerve.

Anterior intramuscular transposition is a seldom considered alternative to other surgical methods in management of cubital tunnel syndrome. Placement of the ulnar nerve anteriorly within the flexor-pronator mass removes it from a vulnerable subcutaneous position without extensive dissection. Of 52 sequential procedures, 45 extremities in 40 persons were available for follow-up (mean, 28 months after operation). By use of a 12-point scale of objective and subjective parameters, there were 87% good or excellent results; 4% were graded fair, and 9% were graded poor. Age, duration of symptoms, and conduction velocity were not of prognostic value. Although 69% of patients had other compressive neuropathy or tendinitis, this did not adversely affect results. Those with changes seen by electromyogram or work-related compensable injury had a poorer prognosis.

Activities of Daily Living↗