Radial Styloid Research Articles

Wrist denervation of the posterior interosseous nerve through a volar approach: a new technique with anatomical considerations.

Full or selective wrist denervation is an effective treatment for chronic wrist pain. In this cadaveric study, a volar approach for prophylactic denervation of the posterior interosseous nerve (PIN) and the anterior interosseous nerve (AIN) was assessed, which can simultaneously be performed during volar approaches for distal radius fracture fixation or in combination with metalwork removal. In total 40 adult upper limbs, embalmed using Thiel's method, were investigated. Group 1 included 20 limbs of which the distances between AIN and PIN to the ulnar margin of radius were measured at levels 6, 8 and 10cm proximal to the styloid process and the distance radial styloid process to proximal border of pronator quadratus which might be useful as an intraoperative landmark. Subsequently further additional 20 adult limbs (group 2) were used. Transection of the PIN via this volar approach at the evaluated best level of step 1 was performed and evaluated by dissection via a dorsal approach. In group 1, the PIN runs within the interosseous membrane, from the ulnar border of the radius, 6.4mm (SD 2.66) at 6cm, 8.4mm (SD 2.28) at 8cm and 3.75mm (SD 5.46) at 10cm proximal to the radial styloid. The AIN runs within the interosseous membrane, from the ulna edge of the radius, 7.5mm (SD 2.4) at 6cm, 7.3mm (SD 1.95) at 8cm and 2.35mm (3.42) at 10cm proximal to the radial styloid. AIN and PIN were in close proximity at the 8-cm level which equals a 1-cm distance proximal to the pronator quadratus border. Group 2 showed a successful transection of the PIN through a single volar surgical approach in additional 18 out of 20 adult upper limbs. This study shows the local anatomy of the PIN, allowing denervation via a volar approach.

Four-corner fusion using a specialized circular locking plate

Four-corner fusion associated to scaphoid excision is a standard procedure for advanced carpal collapse stage II and III. The purpose of this study is to evaluate the effectiveness of the four-corner technique using a specific designed locking plate of latest generation (Flowero, KLS-Martin) in the treatment of these degenerative clinical conditions. From October 2012 to December 2015, 13 patients, 11 males and 2 females, underwent to scaphoidectomy and four-corner arthrodesis using the Flowero (KLS-Martin) circular locking plate. The surgical technique were standardized. Through a dorsal approach, after the denervation of the posterior interosseous nerve, the scaphoid and the tip of the radial styloid were excised. The articular surfaces of the lunate, capitate, triquetrum and hamate were prepared, an autologous bone graft was inserted and the bones were always fixed by the same circular plate. The wrist has been immobilized for 20 days and then the rehabilitation started. Three patients were affected with a scapho-lunate advanced collapse (SLAC) and 10 with a scaphoid nonunion advanced collapse (SNAC). The mean age is 48 years. The mean follow-up is 22 months (range 6–44 months). All patients underwent a CT scan to study the real achievement of the fusion and a clinical evaluation, including wrist functional scoring, pain and personal satisfaction. Only 2 patients did not show a complete fusion at the CT scan evaluation. All patients are satisfied by the operation. They returned to their work and manual activities with mild limitation. Nowadays, they do not complain pain anymore, except the patients who did not obtain the bone fusion. The reduction of range of motion affects mostly the flexion. The grip strength is better than before the surgery. The four-corner arthrodesis with circular locking plate is a good and safe technique that allows a satisfactory recovery.

Sensory nerve supply of the distal radio-ulnar joint with regard to wrist denervation.

The objective of this study was to determine the precise departure points of the articular branches innervating the distal radio-ulnar joint from the anterior and posterior interosseous nerves. The study sample consisted of 116 upper limbs from adult human cadavers. The articular branches were prepared under the dissection microscope to take measurements using the radial styloid process as point of reference. The articular branch departed from the anterior interosseous nerve at a mean distance of 2.9 cm proximal to the styloid for a radius length of 20.5 cm, and 3.7 cm for a radius length of 26.5 cm, respectively. For the posterior interosseous nerve, the departure point was at a mean distance of 3.1 cm (radius length of 20.5 cm) and at 4.0 cm (radius length of 26.5 cm). Apart from a single branch from the posterior interosseous nerve, all articular branches were located distal to the proximal border of the pronator quadratus. Results indicate that wrist denervation from the volar approach, if performed at the proximal border of the pronator quadratus, or from the dorsal approach at a distance of 4.8 cm (for a radius length of 20.5 cm) or 6.2 cm (for a radius length of 26.5 cm) proximal to the radial styloid process, will eliminate the nerve supply to the distal radio-ulnar joint in the majority of cases.

Surgical Strategy and Techniques for Low-Profile Dorsal Plating in Treating Dorsally Displaced Unstable Distal Radius Fractures.

Background The low-profile dorsal locking plating (DLP) technique is useful for treating dorsally comminuted intra-articular distal radius fractures; however, due to the complications associated with DLP, the technique is not widely used. Methods A retrospective review of 24 consecutive cases treated with DLP were done. Results All cases were classified into two types by surgical strategy according to the fracture pattern. In type 1, there is a volar fracture line distal to the watershed line in the dorsally displaced fragment, and this type is treated by H-framed DLP. In type 2, the displaced dorsal die-punch fragment is associated with a minimally displaced styloid shearing fracture or a transverse volar fracture line. We found that the die-punch fragment was reduced by the buttress effect of small l-shaped DLP after stabilization of the styloid shearing for the volar segment by cannulated screws from radial styloid processes. At 6 months after surgery, outcomes were good or excellent based on the modified Mayo wrist scores with no serious complications except one case. The mean range of motion of each type was as follows: the palmar flexion was 50, 65 degrees, dorsiflexion was 70, 75 degrees, supination was 85, 85 degrees, and pronation was 80, 80 degrees; in type 1 and 2, respectively. Conclusion DLP is a useful technique for the treatment of selected cases of dorsally displaced, comminuted intra-articular fractures of the distal radius with careful soft tissue coverage.

Comparing radial styloid size between osteoarthritic and healthy wrists: a pathoanatomical three-dimensional study.

IV.

Case control study on clinical effects of arthroscopic treatment for stenosing tenosynovitis of radial styloid process

To investigate the clinical effect of arthroscopic treatment for stenosing tenosynovitis of radial styloid process. Ninety nine patients diagnosed as stenosing tenosynovitis of radial styloid process from August, 2009 to July, 2013 were divided into three groups, including arthroscopic treatment group(32 cases), traditional operation group (34 cases) and local blocking therapy group(33 cases). Ache, tenderness, swollen situations and movement degrees of wrist joints and thumbs were observed before treatment and one week and one month after treatment. Total effective rates were calculated. Pain score of the wrist and thumb in activity state was lower in arthroscopic treatment group and traditional operation group than that in local blocking therapy group one week and one month after treatment(P=0.044, 0.039). Local pain score was lower in arthroscopic treatment group and traditional operation group than that in local blocking therapy group one month after treatment(P=0.017). The total symptom score was lower in arthroscopic treatment group and traditional operation group than that in local blocking therapy group one week and one month after treatment(P=0.007, 0.015). The effective rates one week after treatment in arthroscopic treatment group, traditional operation group and local blocking therapy group were respectively 96.9%, 94.1% and 84.8%, without significant differences(P=0.213). The effective rates one month after treatment in these three groups were respectively 93.8%, 97.1% and 72.7%, with significant differences(P=0.006). Compared with traditional operation and local blocking therapy, arthroscopic treatment has certain effects for the treatment of stenosing tenosynovitis of radial styloid process, with less operation trauma and complications, and it is worthy of clinical promotion.

An Anatomical Study to Demonstrate the Proximity of Kirschner Wires to Structures at Risk in Percutaneous Pinning of Distal Radius Fractures.

Distal radius fractures are often treated using percutaneous Kirschner wires (K-wires). The sensory nerves in this area, extensor tendons, radial artery and cephalic vein are at risk of injury in this procedure. We undertook a cadaveric investigation to identify probability of damage to these 'at risk' structures by measuring their distances in relation to standard K-wire sites. Nine upper limbs from six formalin-preserved cadavers were studied. Four K-wires were placed percutaneously simulating fixation of a distal radius fracture. Careful dissection was done preserving the original position of neurovascular and tendinous structures. Distances to relevant soft-tissue structures from each K-wire were measured using an electronic digital caliper. Distance of superficial nerves from radial styloid and Lister's tubercle was measured to determine their 'safe distance' from these fixed landmarks. None of the superficial nerves were injured by a K-wire. Cephalic vein had been pierced on 4 occasions (4/18) and extensor tendons on 3 occasions (3/18). Wilcoxon signed-rank test was used to compare distance of the superficial nerves from radial styloid and Lister tubercle, and the latter was found to be the safer option. This study highlights the inherent danger in percutaneous K-wire fixation of wrist fractures. Limited size of the area, where K-wires can be positioned, and anatomic variations of neurovascular structures pose obstacles in developing guidelines for reducing risk of injury. We advocate use of mini-open approach and guiding devices to avert complications of inadvertent impalement and damage to these structures.

Dynamic Ulnar Deviation Deformity of Wrist Due to Post Infective/Posttraumatic Contracture of Isolated Musculotendinous unit—A Report of Two Unusual Cases

Keywords Extensor carpi ulnaris.Flexor carpi ulnaris.Z PlastyIntroductionDeformities at wrist are commonly attended in an orthope-dic outpatient department. The causes in young rotatearound epiphyseal plate growth disturbances, which may becongenital as in madelung deformity or acquired afterinfection, trauma or tumor. Shortening of extensor carpiulnaris (ECU) musculotendinous unit as sequelae ofinfection or flexor carpi ulnaris (FCU) musculotendinousunit as sequelae of trauma leading to a dynamic wristdeformity has not been reported in literature yet.Case reportCase 1 A 15 years old male presented with c/o deformity(ulnar deviation) of left wrist for last 6 years. Patient wasapparently all right 6 years back when he suffered trauma todorso ulnar aspect of left upper forearm followed bydevelopment of an abscess, which was incised and drainedby a local practitioner. Patient started developing ulnardeviation at left wrist which kept on progressivelyincreasing (it has been static for last 1 year). Patient hadsome functional disability as a result of this deformity, inparticular, in picking up objects and holding glass (glassholding requires radial deviation at wrist). However thepower grip (in ulnar deviation of hand) was normal. Therewas no complaint of any numbness or weakness.On local examination a 5 cm×2 cm scar was seen ondorso-ulnar aspect of upper 1/3rd of left forearm (i.e. thesite of previous I&D) (Fig. 1a). There was fixed ulnardeviation deformity of left wrist—45° (Fig. 1b). The rangeof supination and pronation was full. Range of motion ofelbow was full and painless. Dorsiflexion and palmarflexion were 80° and 90° respectively. No radial deviationwas possible. Ulnar deviation ranged from 45° to 60° withwrist in neutral dorsi/palmar flexion. On attempt at activeulnar deviation and dorsiflexion by the patient contractionof ECU muscle belly could be felt. Ulnar lengths measuredfrom olecranon tip to ulnar styloid and radial lengths fromradial head to radial styloid were bilaterally symmetricaland hence normal.Ulnar deviation deformity at wrist manifested itselfcompletely on palmar flexion but disappeared on dorsi-flexion (60° ulnar deviation deformity on palmar flexionand no ulnar deviation deformity on dorsiflexion) (Fig. 1cand d) .ECU tendon got taut and became prominent onattempted radial deviation (Fig. 1e).This is a fixed length phenomenon suggestive ofshortened ECU. No neurovascular deficit was found. X-rays of bilateral wrist and left elbow with forearm werenormal. A provisional diagnosis of left ECU contracturewith dynamic ulnar deviation deformity of left wrist wasmade.Written informed consent was taken from the patient andhis parents for surgery and they were also informed that thiscase will be considered for publication in some scientificjournal including electronic publication on the internet.

Mid-term Outcomes in Perilunate Dislocations

Introduction: Perilunate dislocations and fracture-dislocations are often related to fair or poor results. The goal of this study is to analyze radiographic and functional outcomes of surgically treated patients with perilunate injuries. Methods: We assessed a retrospective series of 37 patients (36 male), mean age 36 (range, 17-71), with a mean follow-up of 4 years (range, 1-10.1). All were subject to worker’s compensation. All patients had dorsal perilunate dislocations; there were 13 cases of perilunate dislocation and 24 cases of perilunate fracture-dislocations. Seventeen patients had a scaphoid fracture and 7 presented other fractures (radial styloid, triquetrum, etc.). All patients had surgical treatment with k wire carpus stabilization, open ligamentous repair (24 cases), scaphoid fixation (9 k wire, 8 headless screws), and other bone fixation when indicated. The Mayo wrist score (MWS) was used for functional evaluation. Radiographic examination was focused in osteoarthritis and instability, according to Herzberg classification. We defined poor results patients with at least one of the following: MWS < 60 points, advanced osteoarthritis, scapholunate instability (SL gap > 5 mm or SL angle > 70°), scaphoid nonunion, or major surgery: proximal row carpectomy (PRC), wrist arthrodesis, or nonunion surgery. Results: Patients had a mean flexion of 44.8° (SD 15.2) and mean extension of 46.8° (SD 16.7). Two cases had severe stiffness (less than 30° arc of motion). Mean grip strength was 66% of contralateral (SD 19.2). According to MWS, 1 patient had excellent results, 7 good (19%), 18 fair (49%), and 11 patients poor results (30%). According to our definition of poor results, 24 of 37 (65%) patients had an unsatisfactory outcome. Radiographic evaluation showed 10% of advanced osteoarthritis and 45% of instability signs. Six patients were classified as Herzberg A (normal alignment without osteoarthritis) and 11 patients as A1 (normal alignment with osteoarthritis). One patient showed instability without osteoarthritis (B) and 11 patients showed instability with osteoarthritis (B1). Seven patients had x-rays modified by the treatment (C). Five patients with trans-scaphoid fracture dislocation had nonunion, 4 of them went to bone graft and only 2 of these get union. One scaphoid nonunion went directly to PRC. There were 3 total wrist arthrodesis (2 due to arthritis and 1 due to instability) and 4 PRC, 3 in context of failed nonunion treatment and 1 in a severe and complex instability. Discussion: Perilunate dislocations and fracture-dislocations are complex injuries with a high rate of unsatisfactory outcomes. Our series showed poor clinical outcomes in 65% which correlate with the poor and fair results in the MWS. We observed a high rate of nonunion in trans-scaphoid dislocations, carpal instability, and articular degenerative changes. These factors would be independent of patient functional performance.

Stylalgia-glossopharyngeal neuralgia: Review of anatomy and outcome of management

We investigated the influence of radial styloidectomy on carpal alignment and examined translation of the wrist after sequentially increased styloidectomy of 8 cadaver wrists. The radial aspect of the scaphoid fossa of the distal radius was cut obliquely at 3, 6, and 10 mm from the radial styloid guided by real-time fluoroscopy. Radiographic analysis of the changes of carpal alignment was performed with the wrist in neutral position. Force-displacement curves from the neutral to the radioulnar and palmar-dorsal directions were obtained using a multi-axis testing machine. Results demonstrated no significant malalignment of the carpal bones after radial styloidectomy. Significantly increased radial translation (>40% reduction in stiffness), however, was observed due to the loss of radial articular contact after 6- and 10-mm radial styloidectomies. Significant ulnar and palmar carpal displacement also was noted after 6- and 10-mm radial styloidectomies, with 6 specimens demonstrating moderate ulnar and palmar translation and 2 demonstrating notable increased palmar and ulnar translations. We conclude that there is a definite risk of increased carpal instability with radial styloidectomy procedures. A styloidectomy of no more than 3 to 4 mm is recommended. (J Hand Surg 2001;26A:85-93. Copyright © 2001 by the American Society for Surgery of the Hand.)

Three-Corner Fusion for Management of SNAC and SLAC Wrists

Objective: Presenting the results of fusion of the lunate bone with capitate and hamate bones plus excision of scaphoid and triquetrum in management of scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrists, looking in particular at the resulted range of wrist motion. Hypothesis: Four corners fusion is considered the golden standard treatment of SNAC and SLAC wrists in the last decade. It is designed to result in relieving pain while maintaining a reasonable hand grip power and preserving some wrist mobility. Yet, many of the candidates wished to have a better arc of wrist movements. Materials and Methods: In a longitudinal study, 3 corner fusion procedure has been performed in 18 patients (12 had SNAC wrists and 6 had SLAC arthritis). Whereas, fusion between lunate, capitates, and hamate was performed together with excision of both of scaphoid and triquetral bones. Also excision of 3 to 4 mm of the radial styloid was carried out for all cases. Results: To date, all cases that were operated with this procedure eventually go into union in a period between 8 to 10 weeks. After an average followed-up period of 19 months (range, 13 to 40 months), the mean of flexion-extension arc of motion of their wrists decreased from 67% (preoperatively) to 62% (postoperatively) compared with the opposite side (range, 55% to 74%). The mean postoperative grip strength increased from 52% to 78% of the opposite side (range, 62% to 100%). None of the patients needed any further surgery and 75% were satisfied and 25% were pleased with the results. Conclusions: Results of 3 corner fusion are promising. The resulted range of wrist motion is relatively better than that obtained with 4 corner fusions, while grip strength and other clinical parameters are yet comparable.

Scaphocapitate Fusion in Advanced Kienböck’s Disease

Objective: The treatment goal in Kienböck’s disease is to preserve the integrity and allow revascularization of the lunate and preserve wrist motion while relieving patients’ symptoms. In stage 3 Kienböck’s disease, the lunate is often unsalvageable due to comminution and subsequent collapse. Scaphocapitate (SC) fusion aims at decompressing the lunate while restoring carpal height and maintaining wrist motion. Materials and Methods: We retrospectively reviewed patients with a minimal 1-year follow-up who underwent SC fusion in stage 3A and 3B Kienböck’s disease. Eleven patients were reviewed clinically and radiologically. Pain, Disabilities of Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, satisfaction, wrist range of motion, and grip strength were assessed independently. Preoperative and last follow-up standard films were compared for Lichtman stage, radiocarpal or midcarpal osteoarthritis, scapholunate and radioscaphoid angles, the Stahl index, carpal height, ulnar carpal deviation, and ulnar variance. Results: In all, 7 male and 4 female patients were reviewed. The average follow-up was 4.85 years (1-10.55 years). The average age at the time of surgery was 30.1 years (18.5-36 years). Six patients had a radial shortening at the same time and 2 others had 2 and 23 years prior to SC fusion. The lunate was not explored and always left in place. Preoperative pain was 8 (6-10) and was described as constant by all patients. Visual analogue scale (VAS) significantly decreased after surgery to 1.09 (0-2; P < .0001). Wrist range of motion was mildly but not significantly ( P = .45) improved at follow-up. Preoperative wrist flexion was 35.5° (20°-50°) and wrist extension was 35° (20°-70°). Postoperative wrist flexion was 42.7° (10°-95°) and wrist extension was 41.4° (30°-70°). Wrist range of motion was significantly decreased in comparison with the unaffected wrist. Pronosupination was comparable with the unaffected ( P = .01) side. Grip strength was significantly decreased ( P = .027) with 25.8 kg in comparison with the unaffected side with 34.5 kg. Nine lunates were stage 3B, and 2 were stage 3A. Radiographically, all SC fusions united. Ulnar variance was −1 mm on average. Three stage 3B patients improved to stage 3A on follow-up films. Four patients with more than 4-year follow-up had radiographic dorsal radioscaphoid and radial styloid osteophyte suggesting impingement but was not clinically symptomatic. The carpal height decrease from 1.47 to 1.2 was not statistically significant ( P = .09). Ulnar carpal deviation and Stahl index were unchanged. The radioscaphoid and scapholunate angles were restored to a normal range. Functional outcome was good: Average DASH was 30.45 and PRWE was 23.8. Nine patients thought their wrist was very good or good, and 2 thought that it was fair. Nine out of 11 patients were employed and remained so at follow-up. Two patients changed jobs to less demanding positions. Conclusion: SC fusion is a treatment option for advanced Kienböck’s disease. Pain relief is significant. Wrist range of motion remains similar to the preoperative range. Carpal collapse does not progress and keeping the lunate avoids ulnar translation. However, radiological progression of radioscaphoid arthritis may occur.

Three-dimensional analysis of osteophyte formation on distal radius following scaphoid nonunion.

The purposes of this study were to quantitatively analyze osteophyte formation of the distal radius following scaphoid nonunion and to investigate how fracture locations relate to osteophyte formation patterns. Three-dimensional surface models of the scaphoid and distal radius were constructed from computed tomographic images of both the wrists of 17 patients' with scaphoid nonunion. The scaphoid nonunions were classified into 3 types according to the location of the fracture line: distal extra-articular (n=6); distal intra-articular (n=5); and proximal (n=6). The osteophyte models of the radius were created by subtracting the mirror image of the contralateral radius model from the affected radius model using a Boolean operation. The osteophyte locations on the radius were divided into 5 areas: styloid process, dorsal scaphoid fossa, volar scaphoid fossa, dorsal lunate fossa, and volar lunate fossa. Osteophyte volumes were compared among the areas and types of nonunion. The presence or absence of dorsal intercalated segment instability (DISI) deformity was also determined. The distal intra-articular type exhibited significantly larger osteophytes in the styloid process than the distal extra-articular type. Furthermore, the proximal type exhibited significantly larger osteophytes in the dorsal scaphoid fossa than the distal extra-articular type. Finally, the distal intra- and extra-articular types were more associated with DISI deformity and tended to have larger osteophytes in the lunate fossa than the proximal type. The pattern of osteophyte formation in the distal radius determined using three-dimensional computed tomography imaging varied among the different types of scaphoid nonunion (distal extra-articular, distal intra-articular, and proximal). The results of this study are clinically useful in determining whether additional resection of osteophytes or radial styloid is necessary or not during the treatment of the scaphoid nonunion.

Intraneural Median Nerve Anatomy and Implications for Treating Mixed Median Nerve Injury in the Hand.

Background: Nerve transfers have resulted in increased interest in the microanatomy of peripheral nerves. Herein, we expand our understanding of the internal anatomy of the digital nerve to the ulnar index and long fingers, the radial long and ring fingers, and the nerves to the second and third web spaces. Methods: The median nerve was dissected from the digital nerves to the antecubital fossa in 14 fresh upper extremities. The distance of proximal internal neurolysis of the fascicles to the second and third web space and proper digital nerves was measured relative to the radial styloid. Plexi encountered during proximal lysis were noted. Results: Digital nerves to the ulnar index and radial long fingers were lysed 2.4 ± 0.5 cm (mean ± SD), and digital nerves to the ulnar long and the radial ring fingers were lysed 3.0 ± 0.6 cm distal to the radial styloid. Fascicles to the third web space were lysed to the takeoff of the anterior interosseous nerve, 21.1 ± 1.4 cm. Plexus groupings were encountered at 4.5 ± 1.6 cm, 8.3 ± 1.2, cm and 16.1 ± 1.9 cm proximal to radial styloid. The fascicles to the second web space were lysed to 5.0 ± 1.2 cm proximal to radial styloid where a plexus grouping was encountered. Another plexus group was found at 3.3 ± 1.3 cm. Conclusions: We demonstrate that extended internal neurolysis of second web space, along with the digital nerves, is technically and clinically feasible. This technique can be used to treat mixed median nerve injury in the hand and wrist.

Anatomic Investigation of Commonly Used Landmarks for Evaluating Rotation During Forearm Fracture Reduction.

Evaluating rotation during open reduction and internal fixation of a forearm fracture is of paramount importance. In challenging cases, surgeons may utilize radiographic relationships between proximal and distal radial and ulnar landmarks to assess rotational position. However, to our knowledge, limited anatomic data are available to confirm these relationships. Six hundred cadaveric radii and ulnae were obtained. Digital representations of the bicipital tuberosity, the radial styloid, the coronoid process, and the ulnar styloid were acquired, and the rotational profiles between respective landmarks were calculated. In order to validate the results and investigate the ability to differentiate rotated osseous positions, each bone was imaged in increments of 10° of rotation and the profile of each landmark was measured. The radial styloid was at a mean of 158° ± 14° of supination relative to the bicipital tuberosity. The ulnar styloid was at a mean of 185° ± 14° of supination relative to the coronoid process. Imaging of the bones in increments of 10° of rotation supported the relationships above. It was also found that a 1-mm difference in profile size corresponded to up to 60° of rotation for the average ulna, compared with 10° for the average radius. Our findings suggest that using the bicipital tuberosity and the radial styloid to assess intraoperative rotation of the radius on anteroposterior radiographs may be of limited value; the landmarks were not generally 180° apart. Although the rotational positions of the coronoid process and the ulnar styloid were, on average, closer to 180°, surgeons should be aware of the wide range of normal anatomy as well as the inability to judge rotation by as much as 60°, even for an "ideal" ulna. This study, to our knowledge, represents the first anatomic investigation of the rotational profiles between the osseous landmarks used to assess forearm rotation after fracture. We recommend that surgeons first image the bicipital tuberosity at its largest profile, supinate the arm 20°, and confirm that the radial styloid is at its largest profile. The ulna can then be assessed to support the lack of rotational deformity in the forearm.

Anatomical Basis for Injection around First Dorsal Compartment of the Wrist: A Fresh Cadaveric Study

Background: It is important to understand the anatomical relationship between the medial and lateral branches of superficial radial nerve (SRN) and the first dorsal compartment to prevent and minimize possible injury to these nerves during various procedures around the tip of radial styloid process (RSP). Objective: To delineate the anatomical location of the SRN in relation to the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons. Study Design: Observational study. Setting: Academic medical center. Methods: The width of the first dorsal compartment, distance between the EPB tendon and the closest medial branch of the SRN, and distance between the APL tendon and the closest lateral branch of the SRN were measured. The distances were measured at the RSP (the tip of the RSP) and RSP+1 (1 cm proximal to the tip of the RSP) levels. Results: The median distances between the EPB tendon and the closest medial branch of the SRN at the RSP and RSP+1 were 6.0 mm (range: 1.6 − 11.0 mm) and 3.2 mm (range: -2.0 − 9.4 mm), respectively. The median distances from the APL tendon to the closest lateral branch of the SRN at the RSP and RSP+1 were -2.0 mm (range: -9.0 − 8.4 mm) and 1.0 mm (range: -7.2 − 8.0 mm), respectively. A high percentage of overlap (up to 59%) was observed between the lateral branch of the SRN and the APL tendon. Limitation: This study is limited by its small sample size. Conclusion: Due to the anatomical proximity of the branches of the SRN and the first dorsal compartment around the RSP, physicians must be cautious during procedures near this location. It is important to approach from above the EPB, rather than from above the APL, when performing blind procedures, although ultrasound guidance is preferable. Key words: Superficial radial nerve, abductor pollicis longus, extensor pollicis brevis, cadaver; wrist, first dorsal compartment

Effective Conservative Treatments for De Quervain's Tenosynovitis: A Retrospective Study

Effective Conservative Treatments for De Quervain's Tenosynovitis: A Retrospective Study

The use of the radial styloid in the extended osteocutaneous radial forearm free flap

Background The osteocutaneous radial forearm free flap (OC-RFFF) remains a useful tool in head and neck reconstruction; however, it can be challenging to harvest sufficient bone for large reconstructions. The extended OC-RFFF is a modification that involves harvest of the distal border of the radius to the tip of the styloid. This increases the length of the bone flap by 2 cm to 3 cm, and the inherent contour of the styloid can be used to reconstruct the anterior curvature of the mandible or maxilla without additional osteotomies that may reduce blood supply. Methods The key steps in harvesting the extended OC-RFFF are described. Six patients with mandibular or maxillary defects underwent reconstruction with the extended OC-RFFF. Patient data including demographics, defect features, reconstruction details and outcomes were collected. Results Of the six patients who underwent the extended OC-RFFF, four had mandibular reconstruction and two had maxillary reconstruction. Two patients underwent reconstruction for osteoradionecrosis and the remainder for malignant disease. The average patient age at the time of surgery was 64.5 years. The length of radius harvested ranged from 8 cm to 14 cm (mean 9.7 cm). Two of six patients required a single osteotomy of their bone flap. Donor site complications included partial skin graft loss in 50% and a radius fracture in two patients. Recipient site complications included one patient with intraoral plate exposure. There have been no cases of nonunion. Conclusions The extended OC-RFFF was a safe and reliable option for bony reconstruction in the head and neck.

Melone's Concept Revisited: 3D Quantification of Fragment Displacement.

We applied quantitative 3D computed tomography to 50 complete articular AO type C fractures of the distal radius and tested the null hypothesis that fracture fragments can be divided according to Melone's concept (radial styloid and volar and dorsal lunate facet fragments) and that each fragment has similar (1) displacement and (2) articular surface area. Thirty-eight fractures fit the Melone distribution of fragments. Radial styloid fragments were most displaced, and volar lunate fragments were least displaced. Volar lunate fragments had the largest articular surface area. While these findings confirm Melone's concepts, the finding that volar lunate fragments are relatively large and dorsal lunate fragments relatively small suggests that alignment of the volar lunate fragment with the radial styloid may be the key element of treatment and the dorsal lunate fragment may not routinely benefit from specific reduction and fixation.

Ultrasonographic Evaluation of the Prevalence of an Intracompartmental Septum in Patients With de Quervain's Disease.

It has been reported that more patients with de Quervain's disease who had undergone surgical treatment had a septated dorsal compartment than did normal cadavers. The purpose of this study was to sonographically evaluate the prevalence of an intracompartmental septum in patients with de Quervain's disease and to compare the prevalence between groups categorized by sex, age, and peripartum status. The authors performed an ultrasonographic examination of 112 wrists from 103 patients with de Quervain's disease. The prevalence of a septum-like structure in the first compartment was compared between men and women, between older (≥40 years) and younger (≤39 years) patients, and between pregnant or lactating women and other patients. The prevalence of intracompartmental septum in patients with de Quervain's disease was 61.6% (69 of 112). Of the 69 wrists with an intracompartmental septum-like structure, 53 showed this structure completely through the level of the radial styloid, and 16 showed it partially on the level of the distal radial styloid. There was no significant difference between any 2 groups categorized by the patients' demographics. The prevalence of intracompartmental septation in the patients with de Quervain's disease was higher than the previously reported prevalence in cadavers and lower than that of patients who underwent surgery. This result was consistent with a previous report that patients with a septated dorsal compartment may be more at risk of contracting de Quervain's disease and more prone to failure of nonoperative treatment.