Limited Wrist Motion Research Articles

Clinical Results of Nonvascularized Metatarsal Articular Bone Grafting for Osteochondral Defects of the Radiocarpal and Distal Radioulnar Joint.

Background Treatment of post-traumatic osteochondral defects in the radiocarpal and distal radioulnar joint with nonvascularized metatarsal articular bone grafting is an option to restore the joint (cartilage) surface and wrist function. Purpose To evaluate the clinical midterm results of 10 consecutive patients who were treated with a nonvascularized metatarsal bone graft for cartilage bone defects of the lunate facet, scaphoid facet, sigmoid notch, or the radial part of the ulnar head. Patients and Methods Patients with isolated osteochondral defects of the lunate facet, scaphoid facet, sigmoid notch, or radial part of the ulnar head, respectively, as a result of wrist trauma were retrospectively identified in a prospectively collected database. The patients symptoms were limited wrist motion and/or pain. Clinical results and complications were extracted from patient's medical files and two questionnaires consisting of the Patient-Rated Wrist Evaluation and additional questions regarding patient satisfaction and return to work and/or hobby. Results Minor complications occurred in three cases and required surgery. In five cases an acceptable donor site foot morbidity was seen at 1 year. One patient was not satisfied due to persistent wrist pain despite adequate range of motion. One patient could not return to its prior work. Another patient could not resume its hobby. Conclusion Retrospective evaluation of 10 cases with resurfacing of the scaphoid facet, sigmoid notch, and/or lunate facet, or radial part of the ulnar head has shown that osseointegration was possible without a vascular pedicle to the graft in all cases with a (mean) follow-up of 5 years. This technique may become an alternative treatment when implants become less available. Level of Evidence Level III.

KIENBÖCK'S DISEASE, AVASCULAR NECROSIS OF THE LUNATE

Introduction: Avascular necrosis of the lunate bone was described in 1910 by the Austrian radiologist Robert Kienböck, which is named after him. A mixture of different factors such as mechanical, vascular and genetic predisposition may be related to the pathogenesis of this disease. As for the natural evolution of the disease, failure in early diagnosis and early treatment may lead to a gradual evolution from stage I to stage IV, causing discomfort to the patient. Objective: to detail the current information related to avascular necrosis of the lunate, description, etiology, classification, imaging presentation and management of Kienböck's disease. Methodology: a total of 32 articles were analyzed in this review, including review and original articles, as well as clinical cases, 20 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: Kienböck, avascular necrosis of the lunate and lunatomalacia. Results: it is the second most frequent cause of avascular necrosis of the carpal bones and generally affects males between 20 and 40 years of age. Nuclear magnetic resonance has a greater contribution due to greater sensitivity and detection of radiographically occult cases, computed tomography also has a good specificity at the time of diagnosis. Radiography at the beginning of the disease does not present evident changes and nuclear scintigraphy presents non-specific findings. In the first stage, the treatment is based on immobilization with a plaster cast or splints. When incomplete necrosis is evidenced in the second stage, conservative treatment can be performed, however with complete necrosis or in the third and fourth stage, it requires "joint leveling" surgery and probably vascular bone grafting or transfer of branches of adjacent arteries. Stage IIIA usually merits lunate restoration, in stage IIIB and Lichtman IV wrist arthrodesis can be used. Conclusions: Kienböck's disease presents with unilateral pain over the dorsal aspect of the wrist, weakness and limited wrist motion, in addition to functional impotence, decreased grip strength, wrist edema, sensory disturbances in the median nerve territory and synovitis, depending on the stage. It is related to the following variables such as ulnar minus or ulnar negative variation, vascular contribution of the lunate bone, morphology of the lunate, radial inclination angle. The diagnosis is clinical and imaging where Lichtman's classification is useful. Treatment will depend on the cause and also on the stage of the disease.

Distal Radioulnar Joint, Distal Ulna Injury, and Lunate Facet Considerations in Distal Radius Fractures.

Injuries to the distal aspect of the ulna and the distal radioulnar joint (DRUJ) commonly occur concurrently with distal radius fractures. These fractures may also involve the sigmoid notch of the lunate facet of the radius. Each of these structures merits consideration when managing ulnar-sided injuries associated with distal radius fractures. Improper management of distal radioulnar complex injuries may result in limited wrist motion, persistent DRUJ instability, and pain despite successful fracture union. The distal ulna is the keystone of the distal radioulnar articulation. An understanding of the components of the distal radioulnar complex and methods to manage injuries of each of these components contributes to improved functional outcomes by restoring this keystone effect. The classification of distal radioulnar injuries discussed herein provides a framework for understanding the disruption of the ligamentous stabilizers of the DRUJ and identifying residual distal radioulnar instability after fracture fixation. Proper treatment of residual DRUJ instability will restore stability and minimize persistent functional impairment.

Carpal Coalition: Is It Really Rare and Incidental Finding?

Objectives: Carpal coalition (CC) defines the combined development of two or more carpal bones. The diagnosis is often made incidentally by the radiographs. Incidence of CC changes with ethnicity. CC may cause various symptoms because of the coalition type and the affected bones. We aim to analyze the incidence of CC, affected bones, define the symptoms and find out the correlation between CC, demographic factors and associated hand anomalies. Methods: A total of 9457 hand and wrist AP radiographs were retrospectively analyzed. 9162 radiographs were included in the study. If a coalition was found, affected bones, patient’s age and gender, clinical findings and concomitant hand abnormalities were recorded. Results: 29 CC cases, including 16 female (55.2%) and 13 male (44.8%) patients were found. The CC incidence was %0.3. Mean age was 34.6 (range between 13-80). There were 25 (86.3%) lunotriquetral coalitions (LTC), 2 capitate-trapezoid coalitions (CTC) (6.9%), 1 (3.4%) hamate-pisiform coalition (HPC), and 1 (3.4%) trapezium-trapezoid coalition (TTC) in the study population. There was non-traumatic wrist pain in 8 (27.5%) cases, and there was limited wrist motion in 1 (3.5%) case. 7 of 8 non-traumatic wrist pain cases had LTC, and 1 of 8 had HPC. LTC was found in the case with limited wrist motion. There was bilateral CC in one patient and concomitant oligodactyly in another one. Conclusion: CC is a rare and often asymptomatic developmental anomaly in our study which is performed with one of the most extensive series in the literature. LTC is the most frequent form. CC should be kept in mind in patients with wrist pain and limited wrist motion.

In Brief: The Lichtman Classification for Kienböck Disease.

In Brief: The Lichtman Classification for Kienböck Disease.

The use of kinematic and parametric information to highlight lack of movement and compensation in the upper extremities during activities of daily living

A problem that is common to the study of upper limb kinematics and gait analysis is the translation of the evidence from kinematic measurements into easily interpretable information on the status of the patient, such as the amount of compensation or lack of motion. In this study parameters that can be helpful in the rapid and clear identification of limited wrist motion and compensation were derived from kinematic data. A group of six subjects (group A) with no hand impairment, average age 32.5 ys SD 10.7 ys, and another group of five subjects (group B), average age 34.2 ys SD 16.8 ys, having suffered from distal radius fracture were tested during a cyclic activity of daily living. The activity simulated page turning. Thorax, shoulder, elbow and wrist angles were measured during this task using a motion capture system. Corresponding angle ranges were also calculated. The active range of motion (AROM) found for Group B was generally lower than that of Group A, particularly for elbow supination and wrist movements, with wrist flexion/extension statistically smaller for group B ( P = 0.02). Additional parameters that took into account lack of movements at the wrist and compensation from shoulder elevation, rotation and elbow pronation/supination proved to be more useful at identifying those subjects of group B outside the normative range and can provide clinicians with a rapid and efficient tool that can shorten the analysis process and help make more informed decisions on therapeutic treatments.

Open Wedge Osteotomy for Malunited Extraarticular Distal Radius Fractures with Plate Osteosynthesis without Bone Grafting

Malunion of distal radius fractures can cause pain, limited wrist motion, or loss of grip strength. The most important factors are incongruity in the distal radioulnar (DRU) joint and radial tilt which causes adaptive carpal instability. The purpose of open wedge corrective osteotomy is to restore congruency with minimal soft-tissue damage. Between 1993 and 2001, 47 patients with malunited extraarticular distal radius fractures who were treated by open wedge corrective osteotomy without bone grafting were included. The patients were divided into two groups, one group with dorsal tilt of the distal radius and one group with palmar tilt. Ulnar variance, radial inclination, and radial tilt were measured before and after operation. Also, the range of wrist motions was tested before and after correction, including grip strength. Fixation was performed with a dorsal or palmar plate, dependent on the side of radial tilt. Improvement of especially radial tilt was seen in both groups. Also, an important increase in wrist motions was observed. Flexion of the wrist improved by 38.0° in the dorsal group and by 43.0° in the palmar group. With respect to rotation of the lower arm, supination improved most by 21.6° and 46.0° in the dorsal and palmar group, respectively. All osteotomies healed within 3 months without secondary displacement even after a short period of immobilization. Corrective osteotomy is a useful additional therapy in the treatment of malunited extraarticular fractures of the distal radius in which bone grafting is not necessary.

Biomechanics of the Steindler flexorplasty surgery: a computer simulation study

Purpose Our goal was to investigate the capacity of a Steindler flexorplasty to restore elbow flexion to persons with C5-C6 brachial plexus palsy. In this procedure the origin of the flexor-pronator mass is moved proximally onto the humeral shaft. We examined how the choice of the proximal attachment site for the flexor-pronator mass affects elbow flexion restoration, especially considering possible side effects including limited wrist and forearm motion owing to passive restraint from stretched muscles. Methods A computer model of the upper extremity was used to simulate the biomechanical consequences of various surgical alterations. Unimpaired, preoperative, and postoperative conditions were simulated. Seven possible transfer locations were used to investigate the effects of choice of transfer location. Results Each transfer site produced a large increase in elbow flexion strength. Transfer to more proximal attachment sites also produced large increases in passive resistance to wrist extension and forearm supination. Conclusions To reduce detrimental side effects while achieving clinical goals our theoretical analysis suggests a transfer to the distal limit of the traditional transfer region.

TRIQUETRAL IMPINGEMENT LIGAMENT TEAR (TILT)

Ulnar wrist pain is a complex problem whose cause often remains elusive. A diagnostic triad of localized triquetral pain, history of a wrist hyperflexion injury, and normal radiographs, accompanied by ulnar wrist swelling and limited wrist motion, is often attributable to a syndrome we have termed triquetral impingement ligament tear (TILT). The mechanism of injury causes a cuff of fibrous tissue to be displaced distally from the ulnar sling mechanism, resulting in chronic impingement on the triquetrum that causes hyperaemia, loss of articular cartilage, and softening of the bone. Surgical repair consists of simply excising the impinging fibrous cuff. The outcome of 44 patients treated for TILT over a 6-year period is reviewed. In all cases, TILT repair resulted in improved wrist motion and strength. Ninety-five percent of patients reported a significant improvement in pain both at rest and with activity.

A comparative study of the surgical procedures to treat advanced Kienbock's disease

We have treated a total of 16 cases of advanced Kienböck's disease, stage III and IV by Lichtman's classification, with triscaphe fusion, tendon ball replacement arthroplasty after excision of lunate, proximal row carpectomy as a salvage procedure and limited wrist fusion, since 1985. All cases were followed for minimal 16 months after each operation. Tendon ball replacement arthroplasty after excision of lunate could not prevent further carpal collapse with persistent chronic wrist pain. The triscaphe fusion or radio-lunate fusion induced a marked limited wrist motion later, and the triscaphe fusion alone was not fit for the treatment of advanced one because of progressive proximal migration of capitate and continuous wrist pain due to ligamentous carpal instability in follow-up. So we tried to simultaneously combine tendon ball replacement arthroplasty after excision of lunate with triscaphe fusion in far advanced Kienböck's disease, and their end results was favorable. Proximal row carpectomy could be done in far advanced Kienböck's disease with reasonably painless wrist motions. The overall end results of proximal row carpectomy are much better than any form of carpal arthrodesis. Conclusively the proper way to treat advanced Kienböck's disease seems to depend on the patient's age, their job and sex, and the stage of disease. And the cause of wrist pain in advanced Kienböck's disease seems due to ligamentous carpal instability rather than osteoarthritis on radio-lunate joint.

An Unusual Source of Wrist Pain.

In brief After weight lifting, a 15-year-old boy pain in his right wrist, had tenderness over the dorsum of the lunate, and had limited wrist motion. Radiographs revealed avascular necrosis of the lunate, or Kienböck's disease, and negative ulnar variance. The patient was successfully treated with an ulnar lengthening procedure and immobilization. This patient's symptoms are typical of Kienböck's disease, which should be considered in the differential diagnosis of any active patient who has wrist pain and limited wrist motion. Treatment of this rare disorder can include immobilization for early-stage disease, or surgery, which is most likely to provide an optimal outcome.

Distal radial osteotomy for malunion of wrist fractures in young patients

Malunion after a fracture of the distal radius in a young patient causes a significant disturbance of wrist function. We have performed distal radial osteotomies in 11 patients to correct radial malunion. Surgery was indicated in young patients with functional disability in the wrist due to limited wrist motion and pain. Many had an unacceptable cosmetic appearance of the wrist. In all patients surgery consisted of opening wedge osteotomies to correct radial tilt and radial angle. In some instances it was not possible completely to restore radial length without a reduction in ulnar length. Post-operatively combined dorsal and volar flexion improved from a mean of 34° to 72°. Combined pronation and supination improved from a mean of 68° to 106°. Pain assessed on a simple simr-point functional score was decreased from a mean of 3.3 to 1.3.

Deformities and problems of the forearm in children with multiple hereditary osteochondromata.

Multiple hereditary osteochondromata is the most common benign bone tumor. Deformities of the forearm are the most frequent cause of functional impairment in these patients. The most common deformity is a combination of relative shortening of the ulna, bowing of the radius and/or ulna, increased ulnar tilt of the distal radial epiphysis, ulnar deviation of the hand, progressive ulnarward translocation of the carpus, and subluxation/dislocation of the proximal radial head. In addition to relative shortening and cosmetic displeasure, these deformities commonly produce limited forearm rotation, limited wrist motion, and, when the radial head dislocates, both elbow pain and loss of motion. This article reviews all surgical procedures currently in use, and attempts to synopsize the current thinking about how best to treat these deformities. Preventing and reducing progression of deformity and functional impairment, particularly radial head dislocation, remain paramount goals, and aggressive management is advocated.

Functional cast immobilization of thumb metacarpophalangeal joint injuries.

A prospective study was performed on 40 patients who were treated with a modified thumb spica cast (MTSC) for injuries involving the region of the metacarpophalangeal joint of the thumb. Twenty-seven of these injuries occurred during sports participation. The immobilization consisted of a fiberglass cast which incorporated the thumb in a balanced position and allowed full flexion and extension of the wrist. Twenty patients had injuries involving the ulnar collateral ligament (five surgical). Three patients had radial collateral ligament injuries (two surgical). Fourteen patients had fractures of the proximal phalanx, including five epiphyseal plate injuries. Two patients had dorsal dislocations and one patient had a metacarpal fracture. One patient with a nondisplaced distal metacarpal fracture was treated with simple immobilization. All patients had successful completion of their treatment within the usual time frame. There was no recurrence or increase in symptomatology during the treatment. There was no residual discomfort, loss of position or malunion of the fractures treated. The advantages of the MTSC include improved functional capabilities during immobilization, good patient acceptance, and no period of limited wrist motion or atrophy of forearm musculature. Our experience has been that the MTSC has been a reliable form of immobilization for treating injuries of the metacarpophalangeal joint of the thumb.

Silicone rubber implants for arthrosis of the scaphotrapezial trapezoidal joint.

Degenerative changes of the scaphotrapezial trapezoidal (ST) joint commonly cause pain and weakness. These patients do not respond to conservative treatment, and for several years effort has been made to find an easy way to relieve symptoms. In a previous report a silicone interposition arthroplasty was described and considered to be a useful method. However, the durability of the elastomer was insufficient, and implant fractures and migration of fragments occurred. Since then the procedure has been modified, and high performance Silastic has been used for interposition. Ten patients have been reviewed, with a follow-up from 6 to 36 months (average 15 months). All patients have had lasting relief from pain and consider they have full hand function, without stiffness or limited thumb or wrist motion. Roentgenographic reviews have neither revealed deterioration nor dislocation or migration of the implant. Untoward bone reactions have not been observed. Implant hemiarthroplasty is indicated only when the degenerative changes are solely confined to the ST joint.