Scapholunate interosseous ligament sectioning adversely affects excursions of radial wrist extensor and flexor tendons

Excursions of tendons around the scaphoid were measured in 6 fresh cadaver forearms to evaluate the role of the scapholunate interosseous ligament (SLIL) in wrist joint motion. Excursions of the extensor carpi radialis longus (ECRL) and brevis (ECRB) tendons and the flexor carpi radialis (FCR) tendon were continuously recorded during wrist flexion, extension, and radial and ulnar deviation. Tendon excursions were measured in the intact wrists and after complete sectioning of the SLIL. Tendon excursions were altered significantly in the major ranges of wrist motion after SLIL sectioning. After ligament sectioning, excursions of the ECRL and ECRB tendons increased significantly in wrist flexion and extension. Excursions of the FCR tendon increased significantly during wrist extension and ulnar deviation. These findings support the concepts that integrity of the SLIL plays an important role in wrist function and that injury of the ligament may cause clinical problems.     

Carpometacarpal arthritis of the thumb

Forty-five flexor carpi radialis (FCR) tendon interposition arthroplasties of the trapezium for the treatment of carpometacarpal osteoarthritis were reviewed. The average follow-up period was 103 months (range, 22-213 months). Pain was reduced in 42 (93%) of the cases. Mobility was equal to that of the unoperated side. Key pinch and grip strengths compared to the unoperated thumb measured 86% and 90%, respectively. The mean distance between the scaphoid and the base of the first metacarpal bone was 7 mm (range, 2-12 mm). Function was improved in 39 (87%) of the cases, and in 42 (93%) of the cases the overall results were satisfactory. The results of this study show that FCR tendon interposition arthroplasty gives satisfactory long-term results.     

An unreported cause of rupture of the extensor pollicis longus tendon

Avulsion fractures of the index metacarpal at the insertion of extensor carpi radialis longus are rare. We report such a fracture and the resulting complication of division of the extensor pollicus longus tendon, by the avulsed bony fragment. Careful clinical assessment and appropriate radiological examination is needed to diagnose this rare fracture and internal fixation is recommended.     

Hand flexor tenosynovitis in rheumatoid arthritis. Prevalence, distribution, and associated rheumatic features

Tenosynovitis of one or more flexor tendons of the hand (mean 3.1 tendons per patient) was noted in 55% of 100 patients with rheumatoid arthritis (RA) examined periodically during a mean period of 5 years. The third flexor tendon was involved most frequently (71% of patients), followed by the second (62%), fourth (53%), fifth (27%), and first (13%). Patients with flexor tendonitis (FT) had a significantly higher prevalence of rheumatoid nodules (56% vs 33%), carpal tunnel syndrome (47% vs 13%), wrist extensor tenosynovitis (47% vs 9%), and elbow epicondylitis (22% vs 7%) than patients without FT. Dupuytren's contracture, DeQuervain's tenovaginitis, flexor carpi radialis and ulnaris tendonitis, and Achilles tendonitis were found exclusively in patients with FT. A control group of 50 non-RA patients with FT had statistically fewer diseased tendons per patient (mean 1.5) and a different digital distribution, the thumb being affected more frequently (P less than 0.05) than in RA patients.     

Volar fracture dislocations of the second and third carpometacarpal joints associated with acute carpal tunnel syndrome

Volar fracture dislocation of the second and third metacarpal bases associated with acute carpal tunnel syndrome in a 17-year-old football player were treated with open reduction, via volar incision to decompress the carpal tunnel, and via a second dorsal incision for internal fixation of the fracture dislocations with Kirschner wire fixation and reinsertion of the avulsed extensor carpi radialis:longus tendon. Anatomic reduction by closed or open reduction is recommended to avoid leaving patients with a weak grip and pain over the site of the fracture.     

Division of the transverse carpal ligament and flexor tendon excursion: open and endoscopic carpal tunnel release

Ten fresh cadaver upper extremities from 10 different subjects were used in this study of the effect of both open and endoscopic carpal tunnel release on flexor tendon excursion. The amount of excursion necessary to bring each finger from the fully extended to the fully flexed position with the fingertip just touching the palm was measured with the extremity mounted in a device that moved the wrist from extension through flexion. Endoscopic carpal tunnel release, open release, and transverse carpal ligament reconstruction were performed with tendon excursion measurements made in each of four wrist positions after each procedure. Fingertip to palm distance was also measured. The measurements of flexor tendon excursion in neutral wrist position with intact transverse carpal ligament served as the norm for each finger and as the denominator in the ratio of postoperative to preoperative excursion distances. The study confirmed the importance of the transverse carpal ligament as a flexor pulley; transection of the ligament increased the amount of flexor tendon excursion necessary to achieve finger flexion and fingertip-to-palm contact. Tendon excursion/digital flexion improved after transposition flap repair. Neither open nor endoscopic carpal tunnel release conferred any particular benefit to flexor tendon excursion postoperatively. The proximal palmar aponeurosis does not seem to have the same pulley effect as the transverse fibers of the distal palm.     

Examples of recapitulation of the phylogenetic stages of development of the wakefulness-sleep cycle in mammalian ontogenesis

The purpose of this study was to determine the relationship between the ulnar nerve and the cubital tunnel during flexion of the elbow with use of magnetic resonance imaging and measurements of intraneural and extraneural interstitial pressure. Twenty specimens from human cadavera were studied with the elbow in positions of incremental flexion. With use of magnetic resonance imaging, cross-sectional images were made at each of three anatomical regions of the cubital tunnel: the medial epicondyle, deep to the cubital tunnel aponeurosis, and deep to the flexor carpi ulnaris muscle. The cross-sectional areas of the cubital tunnel and the ulnar nerve were calculated and compared for different positions of elbow flexion. Interstitial pressures were measured with use of ultrasonographic imaging to allow a minimally invasive method of placement of the pressure catheter, both within the cubital tunnel and four centimeters proximal to it, at 10-degree increments from 0 to 130 degrees of elbow flexion. As the elbow was moved from full extension to 135 degrees of flexion, the mean cross-sectional area of the three regions of the cubital tunnel decreased by 30, 39, and 41 per cent and the mean area of the ulnar nerve decreased by 33, 50, and 34 per cent. These changes were significant in all three regions of the cubital tunnel (p < 0.05). The greatest changes occurred in the region beneath the aponeurosis of the cubital tunnel with the elbow at 135 degrees of flexion. The mean intraneural pressure within the cubital tunnel was significantly higher than the mean extraneural pressure when the elbow was flexed 90, 100, 110, and 130 degrees (p < 0.05). With the elbow flexed 130 degrees, the mean intraneural pressure was 45 per cent higher than the mean extraneural pressure (p < 0.001). Similarly, with the elbow flexed 120 degrees or more, the mean intraneural pressure four centimeters proximal to the cubital tunnel was significantly higher than the mean extraneural pressure (p < 0.01). Relative to their lowest values, intraneural pressure increased at smaller angles of flexion than did extraneural pressure, both within the cubital tunnel and proximal to it. With the numbers available, we could not detect any significant difference in intraneural pressure measured, either at the level of the cubital tunnel or four centimeters proximal to it, after release of the aponeurotic roof of the cubital tunnel.     

Surgical anatomy of the distal radio-ulnar joint and the ulno-carpal joint compartment

Variations in length ratios of both radius and ulna directly influence the profiles of the distal radioulnar joint. During pronation and supination, joint surface incongruity of the two forearm bones permits rotational and translational movements. The ulnocarpal discuss is the central part of the ulnocarpal complex. Together with radioulnar and ulnocarpal ligaments, the ulnocarpal meniscus, the tendon sheath of the extensor carpi ulnaris muscle, the ulnar collateral ligament, and accessory fiber strands the complex guides movements such as pronation and supination and stabilizes the proximal and distal carpal joint.     

Etiological mechanism and treatment of Guillain-Barre syndrome-- Campylobacter jejuni enteritis and the development of anti-ganglioside antibody preceding the syndrome

An ulnar dislocation of the trapeziometacarpal joint is reported. On the posteroanterior radiograph of the wrist, the boney alignment appeared normal, and the only sign indicating a dislocation was a slight widening of the joint. By contrast, a true posteroanterior view of the trapezium clearly demonstrated the metacarpal ulnarly displaced. A late tendon reconstruction of the damaged palmar and medial ligaments produced a satisfactory result.     

Atraumatic retrieval of the proximal end of a severed digital flexor tendon

A suction catheter technique is suggested as the next procedure of choice when proximal digital "milking" with wrist flexion fails to deliver the proximal end of the flexor tendon severed within the digital sheath.     

Effects of tobacco smoking on salivary immunoglobulin levels in immunodeficiency

The extensor carpi ulnaris (ECU) tendon is the only wrist motor tendon that broadly connects with the triangular fibrocartilage complex (TFCC) of the wrist. The goal of this study was to determine the biomechanical effect of the TFCC on the function of the ECU. The effect of avulsion of the TFCC on the changes in mechanics of the ulnar wrist extensor tendon was investigated in 8 fresh-frozen cadaver forearms. Excursion of the ECU tendon was continuously recorded over the functional range of wrist extension and ulnar deviation in intact wrists, wrists with ulnar styloid fractures, wrists with TFCC release from the distal ulna, and after excising the distal ECU tendon sheath. The ECU tendon demonstrated a 30% increase in excursion during wrist extension after release of the TFCC from its attachment on the distal ulna. During 60 degrees of wrist extension, excursion of the ECU tendon was 4.8+/-1.9 mm in the intact wrists and 6.3+/-2.0 mm after TFCC release. This change in excursion represented 1.4 mm of bowstringing for the ECU tendon during 60 degrees of wrist extension. Further incision of the distal part of the extensor sheath produced only 6% increase in excursion of the ECU. Results of this study suggest that the TFCC is an important component of the pulley for the ulnar wrist extensor. These findings imply that disturbance of the wrist extensor after TFCC injury may potentially contribute to abnormal loading and force transmission through the ulnar wrist and the TFCC, and support the growing consensus that integrity of the TFCC should be restored in the presence of TFCC injuries.     

Compression neuropathy of the palmar cutaneous branch of the median nerve by the antebrachial fascia

An isolated compression neuropathy of the palmar cutaneous branch of the median nerve is described in a woman who presented with a small tender mass over the anterior aspect of her distal forearm and complete numbness over the thenar eminence. Surgical exploration revealed thickening of the palmar cutaneous nerve as it passed upwards through the antebrachial fascia on the ulnar aspect of the flexor carpi radialis tendon. Neurolysis of two separate fascicles of the palmar cutaneous branch of the median nerve and excision of a window of antebrachial fascia resulted in complete return of sensation over the thenar eminence.     

The vascularization of human flexor tendons within the digital synovial sheath region--structureal and functional aspects

The intrinsic vascularization of human flexor tendons within the digital sheath region was studied on fresh amputation specimens with the aid of angiographic and histochemical techniques. In the flexor digitorum profundus tendon, three separate vascular systems of various origin and with no or very little communication could be verified. In the flexor digitorum superficialis tendon, two such systems were observed. The volar surface of both tendons is more or less devoid of vessels. Moreover, at the proximal interphalangeal joint level, the flexor digitorum profundus tendon has a volar avascular zone, constituting about 1 mm, i.e., about one-third to one-fourth of the thickness of the tendon. It is assumed that the synovial fluid is of importance for the nutrition of the tendons and that therefore the synovial sheath should be preserved as much as possible.     

Bilateral anomalous insertion of flexor pollicis longus

A case of bilateral insertion of flexor pollicis longus to the proximal as well as the distal phalanges is reported. Initially, this case was diagnosed as congenital absence of the flexor pollicis longus, but surgery revealed an intact tendon, with the abnormality only present in the site of insertion. A survey of the literature on congenital abnormalities of flexor pollicis longus failed to reveal any reports of similar abnormalities.     

Contribution on substitution of lost elbow flexion in atypical post-partum paresis of the plexus brachialis

In a ten-year-old boy with an atypical partial post-partum paresis of the dextrolateral plexus brachialis the function of the shoulder was affected substantially and the flexion of the elbow completely. The musculature of the forearm and hand was preserved completely from the anatomical and functional aspect. In compliance with the parents wish, the possibility of replacement with a muscle from a remote site by microsurgical transfer was abandoned and the authors used the well known method of transposition of the insertion of the m. pectoralis major and new retrograde transposition of the tendon of the m. flexor carpi radialis into this muscle to restore the function of the m. biceps brachii. Through postoperative rehabilitation, 90 degrees flexion of the elbow in a supine position was achieved.     

A case of intestinal amebiasis]

An avulsion fracture of the insertion of the extensor carpi radialis longus tendon is rare. There have been only five reports of this injury in the literature [1, 2, 4]. We describe an additional case in which open reduction with internal fixation gave a satisfactory result.     

Dupuytren's disease affecting the wrist

A unusual example of Dupuytren's disease occurred in a black patient with a strong diathesis. The disease affected the insertion of flexor carpi ulnaris at the wrist as well as the palm.     

Vascular supply of the unsheathed segment of the extensor tendons of the 2d to 5th fingers of the dorsum of the hand]

The dorsal approach to the metacarpal bones is through the peritendinous connective tissue of the extensor tendons. Knowledge of the vascular supply of the distal parts of these tendons, between the distal end of the tendon sheath and the tendon's osseous insertion is important, especially with respect to atraumatic technique. The course and distribution of the vessels to the extensor tendons II-V were investigated. Superficial and deep layers of connective tissue were found to contain blood vessels. The superficial vessels reach the dorsal aspect of the extensor tendon, originating from subcutaneous arteries and the large arteries of the hand. The deep vessels reach the lateropalmar aspect of the tendons and originate from the peritendinous muscular arteries. Vessel distribution suggests a direct relationship between the number of nourishing arteries and the tendon surface area. The vascular supply to the unsheathed parts of the extensor tendons shows morphological adaptations to differential mechanical stress during tendon excursion.     

Hypertrophied palmaris longus muscle, a pseudomass of the forearm: MR appearance--case report and review of the literature

Magnetic resonance (MR) imaging of the forearm was performed to evaluate a presumed forearm soft-tissue tumor in a 26-year-old man. Sagittal and axial images revealed a mass isointense to muscle just medial to the flexor carpi radialis tendon (in the expected location of the palmaris longus muscle). A diagnosis of hypertrophied palmaris longus muscle was made. The radiologist must be familiar with the MR imaging appearance of normal variants of the palmaris longus muscle, as this can obviate surgery.     

Salvage surgery for lateral tennis elbow

We undertook a retrospective analysis of 34 patients (35 elbows) who had prior failed surgical intervention for lateral tennis elbow. Revision surgeries were performed between 1979 and 1994. Each patient's non-operative and operative history was recorded before our salvage revision surgery. At revision surgery, findings included residual tendinosis of the extensor carpi radialis brevis tendon in 34 of 35 elbows. In 27 elbows, the pathologic changes in the extensor carpi radialis brevis tendon had not been previously addressed at all, and in 7 elbows the damaged tissue had not been completely excised. Salvage surgery included excision of pathologic tissue in the extensor carpi radialis brevis tendon origin combined with excision of excessive scar tissue and repair of the extensor aponeurosis when necessary. Based on a 40-point functional rating scale proposed here, 83% of the elbows (29 of 35) had good or excellent results at an average followup of 64 months (range, 17 months to 17 years). To prevent failure of surgical treatment for tennis elbow, the pathologic tissue usually present in the extensor carpi radialis brevis tendon should be resected. Release operations, which weaken the extensor aponeurosis but fail to address the pathoanatomic changes, are not recommended.