Palmar Ligament Research Articles

Scapholunate interosseous reconstruction and imbrication of palmar ligaments

Twenty-eight patients with scapholunate interosseous ligament disruption, carpal instability, and persistent wrist pain were treated by carpal reduction, stabilization, and palmar ligament reconstruction. In twenty-two of these patients pain was well controlled, carpal alignment was maintained, and they were able to resume their previous employment. Grip and pinch strengths averaged eighty-two percent and range of motion averaged seventy-six percent of the normal uninvolved side.

Equine synovial tendon sheaths and bursae: an histological and scanning electron microscopical study

The structure of equine synovial tendon sheaths and bursae has been examined by light and scanning electron microscopy. Tissue samples were obtained from horses of various types and ages with no clinical evidence of sheath or bursal disorders. The interior of both structures was lined by a cellular layer superimposed on a vascular zone supported by a fibrous layer. The pattern of cell distribution of the lining varied from site to site within the same structure depending on the nature of the underlying tissue and on the amount of movement to which the structure was subjected. The cellular layer was predominantly fibrous in nature with scanty, widely separated fibroblasts (eg where it lines the palmar ligament, tendons and paratendons). In the mesotendon and bursal extremities, where the lining is subjected to a positive degree of movement, the cellular layer was areolar in type with well established folds populated by abundant cells oval to round in shape. In foals and yearlings, the supportive layer was mainly around the areolar with patches of adipose tissue; which were gradually replaced by fibrous tissue as the animal grew.

Transverse fracture-dislocation of the trapezium

An unusual case of transverse trapezium fracture with complete displacement of the distal fragment is reported. Diagnosis was delayed and physical findings were minimal. The intact deep palmar (oblique) ligament prevented trapeziometacarpal dislocation (instability). Open reduction and internal fixation resulted in union with excellent thumb function.

Difficult Wrist Fractures

Perilunate dislocations of the wrist have a common pathway of disruption that occurs from extensive dorsiflexion injuries. Open reduction and internal fixation of these injuries is required to provide accurate alignment and the option for ligament repair. Both dorsal and palmar surgical incisions may be indicated. Associated injuries to the median nerve must be recognized. Treatment includes scaphoid and radial styloid stabilization with multiple K-wires or internal compression screw (Herbert or Association for the Study of Internal Fixation [ASIF] screws). In these injuries, the lunate must be reduced first and stabilized. The scaphoid proximal segment follows the lunate unless the scapholunate (SL) ligament is torn. The distal scaphoid fragment, capitate, and triquetrum are reduced and aligned with the lunate and need to be held with K-wires. Ligament repair and augmentation may be necessary at both scapholunate and lunotriquetal areas if there has been serious ligament injury. Palmar ligament repair is often required, and we recommend a palmar exploration in most patients along with release of the median nerve. Surgical treatment results of perilunate fracture-dislocations of the wrist appear better than conservative treatment methods, but complications following both indicate the need for improved internal fixation and fracture-dislocation realignment. These fractures are a real challenge to the treating surgeon who must use patience, precise surgical techniques, and careful roentgenographic study (including tomograms and traction views) to assure the best result.

Locking of the metacarpophalangeal joint of the thumb.

We clinically examined the hands of twenty-three patients and experimented with amputation specimens to clarify the characteristic features and pathomechanism of locking of the metacarpophalangeal joint of the thumb. In all of the patients the locking had resulted from forced hyperextension of the thumb. Every injured thumb showed a mild hyperextension deformity of the metacarpophalangeal joint, with the joint having become fixed. Manual reduction was successful in seven patients, but the other sixteen required open reduction, during which we found that the proximal palmar ligament was ruptured transversely with its distal part riding over the volar prominence of the radial condyle of the metacarpal together with the accessory collateral ligament. These dislocated parts of the ligament formed a constricting bundle on the distal joint surface of the condyle that prevented closed reduction. The locking was released by cutting the constricted ligament bundle. Our description of this mechanism is supported by the experimental evidence that we obtained from examining the amputation specimens.

Arthrotomography of the Wrist

Twenty-one fresh cadaver wrists were studied by arthrography and arthrotomography. Arthrography was unreliable in accurately delineating the palmar radiocarpal ligaments. However, lateral arthrotomograms predictively and precisely outlined the radiolucent radiocapitate and radiotriquetral ligaments. The radial and more distant radiolucent area was the radiocapitate ligament, and the ulnar and more proximal area was the radiotriquetral ligament. A constant radiopaque invagination between the outlines of contrast material demonstrated the sulcus anatomically separating these two ligaments. When the ligaments were transected contrast material entered the substance of the ligaments, rendering them radiopaque and, thus, visible on the radiographs. The authors believe that arthrotomography may be a useful clinical tool in the evaluation of post-traumatic injuries to the palmar radiocarpal ligaments of the wrist.

Anatomy of the palmar fascia on the ulnar border of the hand

Dupuytren's disease sometimes seems to arise from the tendon of abductor digiti minimi or the fascia overlying it. The normal anatomy of these structures is described and the tendon is shown to be of central importance in the organisation of the digital fascia. In particular, its connections with the superficial transverse palmar ligament, Grayson's ligaments and the digital band are demonstrated.

Lunate implant arthroplasty. Evaluation of 19 patients.

The results of lunate implant arthroplasty are unpredictable and many untoward postoperative problems are encountered. A retrospective review of 19 patients operated on for lunatomalacia (Kienböck's disease) by Silastic (HP) implant arthroplasty suggests that prevention of postoperative scapholunate dissociation seems to be the key to successful results. Knowledge of the predominant role played by the palmar ulnolunate and radiolunate ligaments is important to the understanding of this mechanism. The intrinsic stability accomplished by the geometry of the carpal bones requires adequate ligamentous support. This restraint, however, may be weakened by pre-existing absence of certain palmar fibres, by the disease process or by the surgery. In the present study three operative methods have been assessed: dorsal approach and implant stem fixation; dorsal approach, removal of implant stem and Kirschner-wire fixation; volar approach, removal of implant stem, no internal fixation but palmar capsuloligamentous reinforcement. Consistently good results have been obtained using the latter technique. It seems as if most of the usual postoperative problems of lunate implant arthroplasty can be avoided by this method which warrants continued trial.

The microanatomy of Dupuytren's contracture

The palmar fascial ligaments have been examined by microdissection using an operating microscope in fresh and preserved cadaveric hands. The palmar fascia is seen to be a precise three dimensional system of skin ligaments having discreet transverse, longitudinal and vertical fibre systems. In the normal hand there is relative motion between the ligament systems on movement. The longitudinal fibres provide a system of skin anchorage which operates irrespective of the position of the underlying joints and acts particularly to resist shearing forces in gripping. The distribution of the lesions of Dupuytren's Disease has been recorded in a series of clinical cases; nodules, skin pits, distortion of the palmar creases, cords and joint contractures, and the pathogenesis of the disease is related to the anatomy of the palmar ligaments. The disease is described as a process of contracture along anatomical pathways. A hypothesis for the development of Dupuytren's Disease is presented whereby the loss of normal motion between palmar fascial ligaments gives rise on use of the hand to stress concentrations which stimulate fibrous tissue deposition and contracture.

Dupuytren's Contracture:Pathogenesis and Surgical Treatment

In order to understand the pathogenesis and symptomatology of Dupuytren's contracture it is essential to have a thorough acquaintance with the anatomy of the palmar aponeurosis. Such knowledge is also indispensable to the performance of suitable surgical treatment of afflicted hands. Since Dupuytren (1832) demonstrated that changes localized to the aponeurosis are the cause of this deformity there has been a marked interest in the fascial framework of the palm, and the cure obtained by removal of the palmar aponeurosis still justifies an interest in the aponeurosis per se. The purpose of this paper is to report on some original observations on the arrangement of the transverse palmar ligament, and the behaviour of the transverse elements of the palmar aponeurosis in Dupuytren's contracture. From these findings conclusions are made with regard to the pathogenesis of the disease and a technique for selective aponeurosectomy is recommended for the surgical treatment of contracted hands.

The Transverse elements of the Palmar Aponeurosis in Dupuytren's Contracture: Their pathological and Surgical Significance

Some original observations on the anatomy and pathology of the transverse elements of the palmar aponeurosis are reported. The transverse palmar ligament forms a continuous band, strictly limited to the midpalmar region with deep attachments at each end merging with the paratendinous septa bordering the compartment on the radial and the ulnar sides. Throughout its length the transverse band is intimately related to the underlying paratendinous septa and together they form a well defined fibrous tunnel system. The function of this separate anatomical structure is discussed, and related to observations on hands following its removal. In all stages of Dupuytren's contracture it was noticed that the transverse palmar band was not involved in the pathological process, this being confirmed as a constant feature in more than 300 consecutively operated hands. In marked contrast the transverse fibers of the interdigital ligaments were frequently the site of pathological changes, resulting in contracted bands.In th...

Therese Neumann.

<h3>To the Editor:</h3> —Editorial comment in the Nov 24 issue ofThe Journal(<b>182</b>:862) has most of the essential facts about the case of Therese Neumann, the Mystic of Konnersreuth. Several other interesting features may be mentioned. Besides the wounds in the hands, feet, and side, eight also appeared around the head, as from the legendary Crown of Thorns. But nail wounds in the hands must be questioned. The Romans, it is said, drove nails through the wrists because palmar ligaments are too weak to bear the weight of a suspended body.¹If that is so, most of the crucifixial figures extant are inexact. Nevertheless, it is said that the wounds of a stigmatist need not correspond exactly with the real ones but serve by election as a mystical proof of grace.²During 30 years, none of Therese's repetitive and chronic wounds became infected, ulcerated, or had