Percutaneous treatment of carpal, metacarpal, and phalangeal injuries.

Percutaneous fixation of hand fractures is a common technique that takes advantage of the subcutaneous nature of hand bones, their small size, and their limited loading potential for stress placed on hardware. Percutaneous wire fixation supplements cast fixation when plaster cannot hold particular reductions, and allow surgical fixation with limited postoperative swelling. In the first part of the current study, the types of wires that are used for hand fixation, fluoroscopy, helpful instruments, and the basic techniques used for this type of surgery are discussed.

Radial nerve injury after routine peripheral vein cannulation.

The dorso-radial aspect of the wrist and hand is a common location for intravenous (IV) cannulation prior to anesthesia. The sensory branch of the radial nerve lies superficially in this area, and it can be injured during routine insertion of IV catheters. In this case, the nerve was lacerated during insertion and a painful neuroma developed after elective surgery and anesthesia.

Ossification and pseudoepiphysis formation in the "nonepiphyseal" end of bones of the hands and feet.

Metacarpals, metatarsals, and phalanges were studied to assess the developmental morphology of "secondary" ossification in the "nonepiphyseal" ends of these bones as well as the formation of the pseudoepiphysis as an epiphyseal ossification variant. Both direct ossification extension from the metaphysis into the epiphysis and pseudoepiphysis formation preceded, and continued to be more mature than, formation and expansion of the "classic" epiphyseal (secondary) ossification center at the opposite end of each specific bone. Direct metaphyseal to epiphyseal ossification usually started centrally and expanded hemispherically, replacing both physeal and epiphyseal cartilage simultaneously.

Nonepiphyseal ossification and pseudoepiphysis formation.

Direct ossification extending from the metaphysis into the epiphysis preceded and continued to be more mature than formation and expansion of the typical epiphyseal ossification center at the opposite end of each longitudinal bone of the hand and foot. Direct metaphyseal to epiphyseal ossification usually started centrally and expanded hemispherically, replacing both physeal and epiphyseal cartilage simultaneously. When remnants of the "physis" were retained, however, while juxtaposed epiphyseal cartilage was replaced, a pseudoepiphysis formed.

Concomitant skeletal and soft tissue injuries.

The diagnosis and treatment of those injuries most commonly seen in conjunction with distal radius fractures are reviewed in this article. Concomitant tendon, arterial, and nerve injuries often are associated with a high-energy mechanism of trauma. These injuries may complicate an already difficult fracture care plan, especially if the diagnosis of these injuries is delayed.

Computed analyses of the pathomechanics of scaphoid waist nonunions.

The computed tomography scans of both the injured and the normal wrists of nine patients with a scaphoid nonunion of 5 to 120 months' duration were used to create three-dimensional computer models. When the computer images of the normal and the contralateral fractured scaphoids were superimposed, it was possible to calculate the volume of bone that was lost as a result of the injury and its failure to heal, as well as the angular relationship of the fracture components to one another. The amount of the scaphoid bone that was lost varied from 6% to 15% of bone volume and did not show a linear correlation with the duration of the nonunion.

Distal ulnar physeal injury.

We reviewed 18 patients and two traumatic amputation specimens with injuries involving the distal ulnar physis. Type 1 growth mechanism injuries were the most common fracture pattern with premature physeal closure and ulnar shortening occurring in 55% of the patients. Other consequences included radial bowing, ulnar angulation of the distal radius, and ulnar translocation of the carpus.

Carpal orientation from computed reference axes.

Carpal instability is usually diagnosed by abnormal two-plane radiographic angles. These angles are often unreliable. A method that eliminates interpretation of overlapping shadows and uses all of the carpal geometry should improve clinical diagnoses.

Wrist and hand skeletal injuries in children.

When accidents occur, the hand is the part of the body most often thrust out to lessen the consequences, resulting in a wide array of combinations of soft-tissue and chondro-osseous injuries. Pediatric wrist and hand skeletal injuries discussed in this article include growth mechanism injury, fractures and dislocations, nailbed injuries, fingertip injuries, burns, and frostbite.

Digital subtraction arthrography of the wrist.

Digital subtraction arthrography of the wrist was used to identify abnormalities in eighty-six (60 per cent) of 139 patients during a fifteen-month period. Multiple abnormalities were noted in thirty-four (25 per cent) of the wrists. The clinical signs and symptoms in the eighty-six wrists did not always correlate with the defects that were seen on the arthrograms.

Composite wiring of metacarpal and phalangeal fractures.

Composite wiring techniques using various configurations of Kirschner pins and stainless steel wire sutures have been applied to the treatment of 63 fractures of the long bones of the hand. The secure fixation achieved allowed active motion within 1 week of operation. Thirty-three metacarpal fractures achieved a final mean total active motion of 256 degrees (standard deviation 13.

Advanced imaging of the wrist.

In an effort to improve the radiologist's contribution to the evaluation of the painful wrist, the authors have studied the usefulness of a variety of imaging techniques. Preliminary results of these studies, including: 173 conventional CT, 80 3-D CT, 119 postarthrography CT, 138 multiple compartment digital subtraction arthrography and 55 MRI examinations, are reported, and technical aspects of the examinations are described.

Work in progress: postarthrography computed tomography of the wrist: evaluation of the triangular fibrocartilage complex.

This report reviews a work in progress evaluating the use of postarthrography computed tomography (CT) of the wrist in assessing triangular fibrocartilage complex abnormalities. Twenty-two triangular fibrocartilage complex perforations in 119 patients were identified with both multiple compartment arthrography and postarthrography CT. To obtain a double contrast image of the triangular fibrocartilage complex, the postarthrography CT examinations were performed after multiple compartment arthrography and the injection of air into the radiocarpal compartment.

Transulnar percutaneous pinning of displaced distal radial fractures: a preliminary report.

Difficulty in maintaining the reduction of displaced radial fractures has prompted the use of numerous techniques to address this problem. The purpose of this study was to determine if four or five 0.045-in Kirschner pins when placed percutaneously through the ulna into the radius could maintain the reduction of this unstable fracture configuration.

CT of the wrist for the evaluation of traumatic injuries.

Computed tomography (CT) of the wrist can help evaluate many types of posttraumatic injuries, particularly bony trauma. Most wrist fractures can be diagnosed with routine radiography, but problematic cases and complicated healing fractures can be difficult to evaluate with conventional radiography. CT provides improved contrast resolution and multiplanar imaging.

Mathematical analysis of computed carpal models.

The computed carpal models from digital computed tomography (CT) data obtained in this study compare favorably to natural anatomy. A new application of algebraic analysis of this data provides mathematical markers from which to calculate the position and orientation of each carpal bone. When the origin of the spatial coordinates of a carpal bone is transferred to the centroid of the bone, the data can be treated as three-dimensional pattern vectors describing its surface.

Digital subtraction wrist arthrography: use of double contrast technique as a supplement to single contrast arthrography.

A new technique using double contrast after digital subtraction wrist arthrography is presented. Results of the double contrast wrist arthrograms were essential to the diagnosis, confirmed the diagnosis, or salvaged an otherwise poor or nondiagnostic examination. It was found that intra-articular injection of air augments the information obtained during postarthrogram active motion studies under fluoroscopy.

Treatment of unstable metacarpal and phalangeal fractures with tension band wiring techniques.

The techniques of tension band fixation are applied in the treatment of metacarpal and phalangeal fractures. The technique uses standard, readily available materials. The variability of the fixation techniques allows for secure fixation of virtually any long bone fracture in the hand, even when other methods are not applicable.

Scaphoid orientation and location from computed, three-dimensional carpal models.

Subtle subluxations within the carpus are often difficult to diagnose. Carpal orientation and location can now be quantified by mathematical analysis of computed, three-dimensional models produced from serial CT scans. The technique and its application in the analysis of scaphoid subluxation are described.

Radiography of the wrist.

The painful wrist frequently poses a diagnostic dilemma. Although increased understanding of normal carpal motion has led to more constructive use of roentgenography, the diagnostic acumen of the examiner is greatly enhanced by the standardization of radiographic views as well as by the use of special projections and when indicated, arthrograms.

Carpal tunnel release: analysis of suboptimal results.

The results of carpal tunnel release are generally good, but not all patients obtain complete and long lasting relief. Persistence of signs and symptoms after adequate decompression of the median nerve is uncommon. Forty-seven suboptimal results in thirty-four patients have been evaluated to determine the reasons for failure.