Proximal Wrist Research Articles

Neglected perilunate injuries: Management strategies and long-term consequences: A narrative review

Neglected perilunate injuries are a challenging and often overlooked condition that can result in significant long-term consequences if not properly managed. These injuries, typically resulting from high-energy trauma, involve dislocations and fractures around the lunate bone, with delayed diagnosis leading to complex management scenarios. This narrative review examines the management strategies for neglected perilunate injuries and the associated long-term outcomes. The review explores the efficacy of different surgical approaches, including open reduction and internal fixation, proximal row carpectomy, wrist fusion, and bone retinacular bone graft scapholunate reconstruction. By evaluating the existing literature, this article highlights the critical need for early diagnosis and appropriate intervention to minimize the risk of post-traumatic arthritis and other degenerative changes.

Clinical Features of ACPA-Negative and ACPA-Positive Variants of Rheumatoid Arthritis.

: The study included patients with a reliable diagnosis of rheumatoid arthritis (RA) according to the criteria of ACR/EULAR 2010. Depending on the ACPA values, two groups of patients were recruited: ACPA-positive and ACPA-negative, comparable in gender, age, duration of the disease, and therapy. The nature of the onset and course of the disease and the activity of RA were evaluated (according to the DAS28, SDAI, CDAI indices). : The study involved 79 patients with ACPA-negative variant of RA and 79 ACPA-positive patients. The age of patients (Me [IR] (in years)) with the ACPA(-) variant was 52 [39; 62]; with the ACPA(+) variant, 54 [42; 62]; the duration of the disease (in months) was 59 [23; 122] and 48 [17; 84], respectively. In ACPA(+) patients, a higher disease activity was determined (by the indices DAS 28crp, DAS28esr, SDAI, CDAI), higher values of C-reactive protein and erythrocyte sedimentation rate, and a greater number of painful and swollen joints (p < 0.05). According to the localization of the involved joints, arthritis of the proximal interphalangeal, metacarpal, wrist and shoulder joints was more often determined in ACPA(+) patients. Systemic manifestations of RA at the time of examination and in the anamnesis were statistically significantly more common in ACPA(+) (32.9%) than in ACPA(-) (17.7%) patients. Of the systemic manifestations, rheumatoid nodules were more common in ACPA(+) patients, whereas a tendency to a higher frequency of neuropathy, sclerites, and episcleritis was revealed in ACPA(-) patients. . In patients with ACPA(-) subtype, clinical signs of joint damage and the inflammatory component are less pronounced compared to ACPA(+). However, the mixed picture of manifestation, the less "bright" course of the disease, the absence of characteristic immunological biomarkers necessitate long-term and careful monitoring of this group of patients. At the same time, the subjective severity of the disease and dysfunction due to ankylosing joints do not differ from the ACPA(+) variant of RA.

Muscular branches from the ulnar artery are the basis for a pedicled partial flexor digitorum superficialis muscle flap.

The feasibility of a pedicled flexor digitorum superficialis muscle flap was studied in 10 fresh cadavers. The number, length and distance from the flexion wrist crease of muscular branches from the ulnar artery in the distal 10 cm of the forearm were recorded. The mean number of muscular branches was 2.7 (range 1-4). The mean distance of the most distal branch was 35 mm (range 26-40) from the proximal wrist flexion crease. Its mean length was 20 mm (range 16-26). A partial muscle flap was raised on the most distal branch and transposed over the median nerve in the distal forearm. Dissection and transposition of this flap were feasible in all specimens. The reliable pattern of muscular branches to the flexor digitorum superficialis allows the elevation of a pedicled partial muscle flap that can cover the median nerve in the distal forearm.Level of evidence: V.

The Relationship Between the Wrist Flexion Creases and the Volar Radiocarpal Joint: A Cadaveric Study.

Surgical approaches to the volar radiocarpal joint have historically entailed wide exposure, possibly contributing to poor wound healing and wrist denervation. To avoid wound complications and wrist denervation, minimally invasive and percutaneous approaches to the volar radiocarpal joint have been proposed. To help guide these minimally invasive or percutaneous approaches to the joint, we sought to characterize the relationship between the volar wrist flexion creases and the volar radiocarpal joint. We propose that the wrist flexion creases will be a reliable method for localizing the joint. Ten cadaveric upper-extremity specimens consisting of fingertip to mid forearm were obtained. Measurements from the proximal and distal wrist flexion creases were taken via fluoroscopy and gross dissection. The wrist flexion creases were located distal to the volar radiocarpal joint in all specimens. The volar radiocarpal joint was located 7 and 16 mm proximal to the proximal and distal wrist flexion creases, respectively. The radiographic anatomy correlated well with the underlying deep anatomy. The wrist flexion creases can serve as a reliable superficial landmark for the identification of the volar radiocarpal joint. These landmarks aid clinicians in performing or interpreting a physical examination or in performing minimally invasive or percutaneous approaches to the volar radiocarpal joint.

718 Estimation of Total Body Surface Area Burns in a Bilateral Above-Knee Amputee Patient

Abstract Introduction The burn injury extension estimate is necessary for the initial IV fluid resuscitation planning, however, current Wallace rule of nines, Lund &amp; Browder charts as well as smartphone applications are based anatomical models with full body integrity. The purpose of this paper is to accurately estimate the TBSA burned in a bilateral asymmetric above-knee amputee patient. Methods An amputation is defined as major amputation when the level is at or proximal ankle or wrist. We present a case example of an 80-year-old patient with a past medical history of long-standing type 2 diabetes mellitus with inadequate metabolic control, left above-knee amputation seven years ago, as well as a contralateral asymmetric above-knee amputation seven months before hospital admission. The patient was brought to the emergency department one hour after suffering burn injuries by fire at his shelter. Upon his arrival inhalational injury was ruled out, and at physical examination second and third-degree burns were noted circumferentially on both above-knee stumps, genitalia, right flank, lower abdomen and back, right hands and forearm, as well as left hand digits (Figure 1A-B). Initial TBSA burned was estimated using the E-burn application yielding a 27% extension; however, this percentage would correspond to patient with full integrity of both lower limbs (Figure 2A) Results This is the first major amputee burned patient of 285 cases admitted for in-hospital treatment at our institution from March 2020 to October 2022. After performing an online search on MEDLINE/Pubmed (keywords: TBSA, estimation, amputated) we found only one published paper in 2020 which presented a Correction Factor (CF) formula for a hypothetical burn patient with bilateral and symmetric fore-quarter amputation. We estimated the amputated surface area (13.7%) with e-burn, to calculate the major amputee CF published in 2020 and test it on a clinical setting. By means of the following formula (Figure 1C): CF = 100 / (100 - % of amputated body part) CF = 100 / (100 – 13.7) CF = 100 / (86.3) = 1.15 Finally, the initial TBSA burnt was multiplied by the CF to adjust it accordingly to major amputations of the patient, as follows: Originally estimated TBSA burnt (27%) x CF (1.15) = 31.05 % (Figure 2B-C) Conclusions This case report serves as an example of the clinical application of the Correction Factor for major amputees burn patients which can be easily estimated with the aid of smartphone applications such as e-burn in mismatched bilateral amputations. Applicability of Research to Practice To our knowledge this is the first clinical application of the major amputee CF, which its simplified estimation by means of E-burn could be of use for burn centers with higher volume.

Clinical features of ACPA-negative and ACPA-positive variants of rheumatoid arthritis

The aim of the study was to study the features of the clinical picture of the disease in patients with ACPA-negative and ACPA-positive variants of rheumatoid arthritis.Materials and methods. The study included patients with a reliable diagnosis of rheumatoid arthritis (RA) according to the criteria of ACR/EULAR 2010. Depending on the values of the ACPA, two groups of patients were recruited: ACPA-positive and ACPA-negative, comparable in gender, age, duration of the disease and therapy. The nature of the onset and course of the disease, the activity of RA were evaluated (according to the DAS28, SDAI, CDAI indices).Results and discussion. The study included 79 patients with ACPA-negative variant of RA and 79 with ACPA-positive. Age of patients (Me [IR], in years) with the ACPA(–) variant was 52 [39; 62], with the ACPA(+) – 54 [42; 62], the duration of the disease (in months) is 59 [23; 122] and 48 [17; 84] respectively. In ACPA(+) patients, higher disease activity was determined by the indices DAS28-CRP, DAS28-ESR, SDAI, CDAI, values of C-reactive protein and erythrocyte sedimentation rate, a greater number of painful and swollen joints (p&lt;0.05). According to the localization of the involved joints, arthritis of the proximal interphalangeal, metacarpal, wrist and shoulder joints was more often determined in ACPA(+) patients. Systemic manifestations of RA at the time of examination and in the anamnesis were statistically significantly more common in ACPA(+) (32.9%) than in ACPA(–) (17.7%). Of the systemic manifestations, rheumatoid nodules were more common in ACPA(+) patients, a tendency to a higher frequency of neuropathy, scleritis and episcleritis was revealed in ACPA(–) patients.Conclusion. In patients with ACPA(–) subtype, clinical signs of joint damage and the inflammatory component are less pronounced compared to ACPA(+). However, the mixed picture of manifestation, the less “bright” course of the disease, the absence of characteristic immunological biomarkers necessitate long-term and careful monitoring of this group of patients. At the same time, the subjective severity of the disease and dysfunction due to ankylosing joints do not differ from the ACPA(+) variant of RA.

Recovery of Patients With Upper Limb Paralysis Due to Stroke Who Underwent Intervention Using Low-Frequency Repetitive Transcranial Magnetic Stimulation Combined With Occupational Therapy: A Retrospective Cohort Study

ObjectivesThe combination of repetitive transcranial magnetic stimulation (rTMS) and motor practice is based on the theory of neuromodulation and use-dependent plasticity. Predictive planning of occupational therapy (OT) is important for patients with rTMS conditioning. Recovery characteristics based on the severity of pretreatment upper extremity paralysis can guide the patient’s practice plan for using the paretic hand. Therefore, we evaluated the recovery of patients with upper limb paralysis due to stroke who underwent a novel intervention of rTMS combined with OT (NEURO) according to the severity of upper limb paralysis based on the scores of the Fugl–Meyer assessment for upper extremity (FMA-UE) with recovery in proximal upper extremity, wrist, hand, and coordination. Materials and MethodsIn this multicenter retrospective cohort study, the recovery of 1397 patients with upper limb paralysis was analyzed by severity at six hospitals that were accredited by the Japanese Stimulation Therapy Society for treatment. The delta values of the FMA-UE scores before and after NEURO were compared among the groups with severe, moderate, and mild paralysis using the generalized linear model. ResultsNEURO significantly improved the FMA-UE total score according to the severity of paralysis (severe = 5.3, moderate = 6.0, and mild = 2.9). However, when the FMA-UE subscores were analyzed separately, the results indicated specific improvements in shoulder/elbow, wrist, fingers, and coordination movements, depending on the severity. ConclusionsThis study had enough patients who were divided according to severity and stratified by lesion location and handedness parameters. Our results suggest that independently of these factors, the extent of recovery of upper limb motor parts after NEURO varies according to the severity of paralysis.

The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images.

Iatrogenic injury of the median nerve has been reported after endoscopic carpal tunnel release and corticoid injection. In 784 MR images of the wrist, the position of the median nerve in relation to the palmaris longus tendon was analysed. The ulnar edge of the median nerve was found medial to the palmaris longus tendon in 14% and 36% of patients at the proximal wrist crease and entrance of the carpal tunnel, respectively, compared with 23% and 40% of patients with carpal tunnel syndrome (88 patients). The position of the median nerve in relation to the palmaris longus tendon varies widely. It is suggested that the palmaris longus tendon may not be considered a safe landmark to locate the position of the median nerve and care should be taken when introducing an endoscopic instrument or during steroid injection for carpal tunnel syndrome.Level of evidence: IV.

CAN TEMPORARY ARTERY CATHETERIZATION EXTEND LIMITS OF ISCHEMIA TIME FOR MACROREPLANTATION?

To analyze patients with traumatic proximal wrist upper limb amputations with prolonged ischemic time who underwent temporary artery catheterization to assess stump viability and results. A case-series study including all patients with a proximal wrist upper limb amputation and a cold ischemic time equal to or above six hours from 2017 to 2021. In total, two surgeons operated eight patients who had experienced forearm amputation injuries. Median ischemia time totaled eight hours. All patients required additional surgeries, most commonly split-thickness skin graft or fixation revision (three patients). This study obtained five successful macroreimplantations. The mean cold ischemia time was longer in the group with successful macroreimplantations (7.4 hours) than of the unsuccessful group (9 hours). Macroreplantations require immediate referral to microsurgery and, although temporary artery catheterization helps surgical decision making, the technique seems to fail to influence outcomes. Level of Evidence IV, Retrospective Case Series.

Promising application of a new ulnar nerve compound muscle action potential measurement montage in amyotrophic lateral sclerosis: a prospective cross-sectional study.

Previous studies have shown that ulnar nerve compound muscle action potential recorded by the conventional "belly-tendon" montage does not accurately and completely reflect the action potential of the ulnar nerve dominating the abductor digiti minimi muscle due to the effects of far-field potentials of intrinsic hand muscles. A new method of ulnar nerve compound muscle action potential measurement was developed in 2020, which adjusts the E2 electrode from the distal tendon of the abductor digitorum to the middle of the back of the proximal wrist. This new method may reduce the influence of the reference electrode and better reflect the actual ulnar nerve compound muscle action potential. In this prospective cross-sectional study, we included 64 patients with amyotrophic lateral sclerosis and 64 age- and sex-matched controls who underwent conventional and novel ulnar nerve compound muscle action potential measurement between April 2020 and May 2021 in Peking University Third Hospital. The compound muscle action potential waveforms recorded by the new montage were unimodal and more uniform than those recorded by traditional montage. In the controls, no significant difference in the compound muscle action potential waveforms was found between the traditional montage and new montage recordings. In amyotrophic lateral sclerosis patients presenting with abductor digiti minimi spontaneous activity and muscular atrophy, the amplitude of compound muscle action potential-pE2 was significantly lower than that of compound muscle action potential-dE2 (P < 0.01). Using the new method, damaged axons were more likely to exhibit more severe amplitude decreases than those measured with the traditional method, in particular for patients in early stage amyotrophic lateral sclerosis. In addition, the decline in compound muscle action potential amplitude measured by the new method was correlated with a decrease in Revised Amyotrophic Lateral Sclerosis Functional Rating Scale scores. These findings suggest that the new ulnar nerve compound muscle action potential measurement montage reduces the effects of the reference electrode through altering the E2 electrode position, and that this method is more suitable for monitoring disease progression than the traditional montage. This method may be useful as a biomarker for longitudinal follow-up and clinical trials in amyotrophic lateral sclerosis.

3D Multiple Triangular Prisms for Highly Sensitive Non-Contact Mode Triboelectric Bending Sensors.

Here, a highly sensitive triboelectric bending sensor in non-contact mode operation, less sensitive to strain, is demonstrated by designing multiple triangular prisms at both sides of the polydimethylsiloxane film. The sensor can detect bending in a strained condition (up to 20%) as well as bending direction with quite high linear sensitivity (~0.12/degree) up to 120°, due to the electrostatic induction effect between Al and poly (glycerol sebacate) methacrylate. Further increase of the bending angle to 135° significantly increases the sensitivity to 0.16/degree, due to the contact electrification between them. The sensors are attached on the top and bottom side of the proximal interphalangeal and wrist, demonstrating a directional bending sensor with an enhanced sensitivity.

T2-weighted MRI defines critical compression in the distal carpal tunnel that is relieved after decompressive surgery

SummaryIntroductionDespite Carpal Tunnel Syndrome (CTS) being the most common entrapment neuropathy, its pathophysiology remains debated. Sub-synovial connective tissues (SSCT) within the carpal tunnel are thought to play a role but are poorly characterised. MRI analysis offers potentially novel insights into SSCT characteristics.MethodsA pilot study of T2-weighted MRI was performed in healthy controls (n=7), and in CTS patients (n=16) pre- and 6 months post-surgical decompression. Image analysis was performed to quantify SSCT cross-sectional area, SSCT signal intensity ratio, and wrist index (depth/width) at distal, middle and proximal wrist landmarks.ResultsMedian SSCT signal intensity was lower in the distal carpal tunnel of CTS patients pre-operatively (0.96) compared to controls (1.13; P = 0.008) and normalised post-operatively (1.13, P = 0.001). Median wrist index was also lower in CTS patients pre-operatively (0.60) compared to controls (0.67, P = 0.022), and again normalised post-operatively (0.74, P =0.001). This was attributed to changes in carpal depth in the antero-posterior axis with decompression surgery.ConclusionThis pilot study successfully demonstrated MRI assessment of SSCT in patients with CTS. The decreased SSCT signal intensities suggest predominant changes at the distal tunnel, potentially indicating reduced SSCT perfusion pre-surgery which normalised post-surgery. Our preliminary findings merit further investigation in a larger cohort.

"Idiopathic" Shoulder Pain and Dysfunction from Carpal Tunnel Syndrome and Cubital Tunnel Syndrome.

Background:As a referral center for chronic pain, we see many patients with “idiopathic” shoulder pain and limited range of motion. The combination of mild or subclinical carpal tunnel syndrome and cubital tunnel syndrome may be an underrecognized etiology of symptoms in such patients. Here, we report our treatment algorithm and results for such patients.Methods:Of patients with a chief complaint of shoulder pain, we identified 56 consecutive patients who had pain or tingling with median nerve compression at the proximal wrist crease and positive Tinel’s around the cubital tunnel. They were first provided a night-time wrist orthosis. If still symptomatic, nerve blocks were given to median and ulnar nerves under ultrasound guidance. If symptoms recurred after nerve blocks, nerve conduction studies and surgical release of affected nerves were performed.Results:Six patients had 60% or more pain relief with orthosis (mean 4.7 ± 0.8 (SD) to 2.2 ± 0.8). Twenty-three patients had nerve blocks and had persistent pain relief (6.0 ± 1.7 to 2.1 ± 1.9) and significant shoulder motion improvement. Twenty-seven patients only had temporal relief and required surgery but postoperatively had persistent pain relief (6.2 ± 2.0 to 1.2 ± 1.0) and improved shoulder motion. qDASH improved from 33.4 ± 20.1 preoperatively to 12.2 ± 7.4 postoperatively.Conclusions:All patients had substantial improvement in shoulder pain and motion with compressive neuropathy treatments. Targeted physical examination can identify these patients, who can have significant improvement with appropriate diagnosis and treatment. The study sheds light on an underrecognized cause of shoulder dysfunction.

Effect of Proximal Row Carpectomy and Wrist Arthrodesis on the Resting Length of Extrinsic Digit Flexor Tendons: A Cadaveric Study

Background Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis.Methods Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height.Results Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00–3.00 cm). A weak direct relationship (R = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated (p = 0.811).Conclusion This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.

Effectiveness and safety of surgical treatment of carpal tunnel syndrome via a mini-transverse incision and a bush hook versus a mid-palmar small longitudinal incision

BackgroundMinimally invasive surgery for carpal tunnel syndrome has been consistently the mainstay of treatment. In this study, we developed a novel bush hook via a mini-transverse incision at proximal wrist crease to surgically treat carpal tunnel syndrome and our aim was to compare the results with those of mid-palmar small longitudinal incision in carpal tunnel release.MethodsThis is a retrospective study on patients who received a mini-transverse incision and a novel bush hook or a mid-palmar small longitudinal incision for treatment of carpal tunnel syndrome. The decision to receive either technique was made mainly based on patients' choice. The clinical results were evaluated at 1 week, 1 month, 3 and 6 months postoperatively and compared.ResultsIn total, 58 patients in mini-transverse incision group and 74 in mid-palmar longitudinal incision group were include. The follow-up period was 6.8 ± 1.6 months. The mini-transverse incision group had a significantly smaller incision (4.3 ± 0.4 mm vs. 26.2 ± 1.6 mm), shorter surgical time (7.8 ± 2.6 min vs. 19.7 ± 2.8 min), but not for hospital stay (3.2 ± 1.9 vs. 3.6 ± 2.2 days). Both groups showed significant improvement from baseline level at any time points postoperatively (all P < 0.001). At 1 month and 3 months, the mini-transverse incision group showed a significantly better improvement of VAS, SSS and FSS score (P < 0.05). At 6 months, the differences were no longer significant (P > 0.05). In addition, the mini-transverse incision group showed a significantly reduced time to return to the work and activities, tendency to higher rate of excellence and good outcomes and fewer complications.ConclusionsThis novel technique via a mini-transverse incision and bush hook showed better clinical effectiveness and safety, and can be considered as an alternative for wrist tunnel release after the results are validated by higher-level evidence studies.Evidence level: III.

A Cross sectional Study on Estimation of Stature from Forearm length in the age group of 18 to 25 years in Telangana population

A cross sectional study on correlation of the stature from forearm length was conducted in the population of Telangana region of India, A total of 150 members participated in the study among 75 males and 75 females in the age group of 18 to 25 years. The aim of the study is to estimate stature from a fragmentary body part forearm in the population of Telangana and to derive a separate regression equation for both right and left hand and for both male and female individuals. Measurement of the body part forearm length has taken as distance from the tip of the olecranon to proximal wrist crease in semi flexed posture measured by using vernier caliper. Statistical analysis was done by descriptive statistics like mean standard deviation, correlation coefficient and linear regression. P vale &lt;0.05 was considered as statistical significant. The data was analyzed by using SPSS version 25 software. The formula for right forearm is y = 50.76 + 4.18 X, left forearm is y = 50.89 + 4.19 X for total study group. For male population the formula for right forearm is y = 67.80 + 3.62 X, left forearm is y = 72.84 + 11.19 X. For female population the formula for right forearm is Y = 68.45 + 8.13 X and for left forearm is Y = 64.88 + 3.60 X.We found highly significant correlation between the forearm length and height of the individual. We observed a separate regression equation for right and left hand in both male and female population yield better result. We also observed left forearm equation is more accurate than right forearm. The height of the individual is about 6.1 times of forearm length. Linear regression formula developed in our study group is more appropriate for Telangana population

Is Palmar Cutaneous Branch of the Median Nerve More Swollen in Carpal Tunnel Syndrome?

Objective To investigate the characteristics of the palmar cutaneous branch of the median nerve (PCBMN) in patient with carpal tunnel syndrome (CTS) using high-resolution ultrasound.MethodsFourteen healthy volunteers (17 wrists) and 31 patients with CTS (41 wrists) were evaluated by high-resolution ultrasound. All patients were classified into three groups based on the electrophysiologic CTS impairment severity: mild, moderate, and severe. Using high-resolution ultrasound, the cross-sectional areas (CSAs) of the PCBMN were measured at the proximal wrist crease, bistyloid line, and distal wrist crease, and the largest CSA was defined as the maximal CSA.ResultsThe maximal CSA of the PCBMN of the control, mild, moderate, and severe CTS groups were 0.27±0.08, 0.30±0.07, 0.35±0.10, and 0.47±0.13 mm2, respectively. The maximal CSA of the PCBMN was significantly larger in the severe CTS group than in the other groups.ConclusionThe PCBMN could be concomitantly affected in patients with severe CTS.

Arthroscopic Debridement and Arthrolysis for the Treatment of Advanced Kienböck's Disease: 18-Month and 5-Year Postoperative Results

Background Salvage procedures, such as proximal row carpectomy, limited or total wrist arthrodesis, and wrist replacement, are generally preferred to treat advanced Kienböck's disease. However, these procedures are particularly aggressive and may have unpredictable results and potentially significant complications. Questions/Purpose This study aimed to present the short- to mid-term clinical and functional results of arthroscopic debridement and arthrolysis in the management of advanced Kienböck's disease. Patients and Methods Fifteen patients in whom Lichtman Stages IIIA to IIIC or IV Kienböck's disease was diagnosed and treated by arthroscopic wrist debridement and arthrolysis were included in this retrospective study. The mean age was 30 years (range: 21-45). The mean follow-up period duration was 36 months (range: 18-60). The Disabilities of the Arm, Shoulder, and Hand (DASH) score, visual analog scale (VAS), wrist range of motion (ROM), and grip strength were measured preoperatively and then again at the final follow-up visit. Results The mean DASH and VAS scores improved from 41 (range: 31-52) and 7.1 (range: 6-8) preoperatively to 13 (range: 8-21) and 2 (range: 0-3; p < 0.001) at the final follow-up visit, respectively. The mean wrist flexion and extension values increased from 32 (range: 20-60 degrees) and 56 degrees (range: 30-70 degrees; p = 0.009) preoperatively to 34 (range: 10-65 degrees; p = 0.218) and 57 degrees (range: 30-70 degrees; p = 0.296) at the final follow-up appointment, respectively, although these findings were statistically insignificant. The mean strength of the hand grip increased from 22.7 (range: 9-33) to 23.3 (range: 10-34; p = 0.372). Conclusion Arthroscopic debridement and arthrolysis may improve wrist function and quality of life due to the preserved ROM and hand grip strength after short- to mid-term follow-up periods despite the radiographic progression of Kienböck's disease. Level of Evidence This is a Level IV, retrospective case series study.

The Volar Distal Radioulnar Portal in Wrist Arthroscopy: An Anatomical Study.

Background Advances in wrist arthroscopy and the emergence of novel surgical techniques have created a need for new portals to the wrist. The aim of this study was to define and verify the safety of the volar distal radioulnar (VDRU) portal. Description of the Technique The VDRU portal is located ∼5 to 10 mm proximal to the proximal wrist crease, just on the ulnar edge of flexor carpi ulnaris tendon and radial to the dorsal cutaneous branch of the ulnar nerve. The ulnar styloid marks the distal point of the portal. Methods An anatomical study was performed on 12 upper extremity specimens of 6 human cadavers. Iatrogenic injuries of neurovascular structures potentially at risk were assessed, and the distance from the portal to these structures was measured. Results No iatrogenic injuries of the structures at risk occurred. Mean distances from the VDRU portal to the ulnar neurovascular bundle, the radial branch of the dorsal sensory branches of the ulnar nerve (DSBUN), and the ulnar branch of the DSBUN were 9.29 ± 0.26 mm, 8.08 ± 0.25 mm, and 10.58 ± 0.23 mm, respectively. There were no differences between left and right wrists. The distances from the VDRU portal to the ulnar neurovascular bundle and the ulnar branch of the DSBUN were significantly shorter in women; this distance was not less than 7 mm in any case. Conclusions The VDRU portal is safe, reproducible, and facilitates the implementation of various techniques related to triangular fibrocartilage complex pathology.

Body Mass Index Vs Fracture Risk Value Primary Osteoporosis (A Case Study on Women Ages 40-45 Years at Sub-Urban Area)

This study aims to determine the relationship between BMI and fracture risk value primary osteoporosis in women aged 40-45 years in sub-urban areas. And how to optimize social activities in the environment as an effort to reduce the risk of osteoporosis. Body mass index is one of the important risk factors for osteoporosis fractures because the protective effects of subcutaneous fat tissue on bone in elderly women are calculated using FRAX®tool. The WHO in collaboration with the Sheffield's University central of metabolic bone disease has created a calculating device, the WHO risk assessment fracture tool (FRAX®tool). FRAX®tool is an online-based device used to calculate the risk of osteoporosis fractures in major bones, namely proximal humerus, wrist, vertebrae, and femur bone in the next ten years. This research is an analytical study using a cross sectional design, the number of samples is 70 female respondents aged 40–45 years in Kelurahan Melong Asih, Cimahi. The relationship between body mass index and the risk of primary osteoporosis fracture, used the rank spearman correlation test. The results of this study indicate a strong negative correlation between body mass index and the risk value of osteoporosis major, while the relationship between body mass index and risk value for osteoporosis femur fracture was found to be a moderate negative correlation. From the results of the risk of major osteoporosis fracture the lower a person's body mass index, the greater the risk of major primary osteoporosis fracture, whereas the results of the risk of femur fracture are only in obese grade II that is low, while other criteria have the same value, so it cannot be concluded if the lower a person's body mass index, the greater the risk value of the femur fracture. Keywords : Body Mass Index; Fracture Risk Value; Osteoporosis.