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Electrodiagnostic tests such as electromyography (EMG) and nerve conduction velocity studies are commonly ordered during the evaluation of patients with suspected peripheral nerve compression. Although these tests are invaluable extensions of the physical examination, many physicians are unable to interpret the test results, and so they base their operative decisions on electromyographers' impressions. A systematic approach to EMG interpretation allows surgeons to determine the nature and location of lesions as well as the degree of involvement and the viability of affected skeletal muscles.

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Despite the effectiveness of external fixation in the treatment of complex wrist fractures, the complication rate for this modality ranges from 20% to 62%. Common complications are related to the use of percutaneous metal pins and result in an average reoperation rate of 16%. In addition, external fixation is unable to prevent dorsal collapse of the radius or maintain the normal palmar tilt of the radiocarpal joint surface. This complication may predispose to posttraumatic wrist instability and arthritis. The problems with external fixation have prompted a search for a better treatment option. An internal fixator placed through limited incisions on the dorsal aspect of the radius and spanning the fracture site can, in theory, provide the benefits of external fixation without the associated morbidity. This study determined the biomechanical efficacy of internal fixators compared with external fixators using a standardized model for an unstable wrist fracture. Two commercially available metal plates were used as internal fixators. Biomechanical testing of the devices was done, and stiffness was determined. Results showed that the internal fixators were significantly stiffer than were the external fixators in axial loading. Failure in axial loading, specifically compression, is a consistent reason for loss of reduction in intraarticular distal radius fractures. The clinical implications of these results suggest that an internal fixator theoretically can prevent loss of reduction in the axial plane and maintain palmar tilt by acting as a rigid dorsal buttress. In addition, the use of an internal fixator potentially decreases the high morbidity associated with external fixation. Additional investigation into the clinical application of internal fixators for distal radius fractures is needed.

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MR imaging of the wrist has the unique capability of simultaneously demonstrating bone and soft tissue structures. Its exquisite sensitivity for detecting bone marrow edema makes it and ideal screening tool for diagnosing radiographically occult osseous injuries and areas of AVN. This, together with its ability to provide a comprehensive, non-invasive assessment of the ligaments, tendons, nerves, and components of the TFC make MRI a very powerful tool for evaluating patients with wrist pain of uncertain etiology. Its exact role in the work-up of these patients has not been entirely established, but with further advances in technology and the radiologist's understanding of wrist anatomy and pathology, MRI is assuming a more central role in this clinical setting.

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The patient with an unsatisfactory result following carpal tunnel release is fortunately the exception rather than the rule. The vast majority of appropriately selected and treated patients will recover uneventfully without the need for extensive therapy. Although uncommon, the dissatisfied patient presents an extremely difficult management problem. Inasmuch as there are a number of factors that may potentially contribute to a poor result, failure to recognize and treat excessive edema and stiffness in the early postoperative period are responsible for a significant percentage of poor results. Patients with a poor result present with three basic signs or symptoms, which may occur in combination or alone. These signs and symptoms include excessive edema, stiffness, and hypersensitivity. If left untreated, these are the patients who will go on to develop persistent median nerve symptoms, stiffness, and possibly even reflex sympathetic dystrophy or sympathetically mediated pain. If identified early and placed in an appropriate therapy program, most of these patients will receive the proper treatment and will ultimately be satisfied with their result. The author presents here a protocol for the postoperative management of the patient who has undergone carpal tunnel release surgery, with emphasis on the recognition and treatment of those patients at risk for a poor result.

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To investigate the relationship between hand dominance and the risk of major hand injury, the case records of 125 patients who had been treated for digital amputation were retrospectively reviewed. A second group of 116 patients treated for minor hand trauma was similarly evaluated. The incidence of left-hand dominance among the digital amputation group was 35%, and among the minor trauma group the incidence was 11%. The left-handed were more likely to have an amputating injury of their dominant hand than were the right-handed (70% compared with 51%, respectively). The most common mechanism of amputating injury was by power saw. The present data suggest that left-handed individuals have a relative risk of sustaining an amputating injury that is 4.9 times greater than the right-handed individuals, while minor hand trauma occurs at rates proportional to the distribution of left handedness within the population. Additional safety measures and the redesigning of tools, assembly lines, and workstations are recommended to help decrease the incidence of serious hand injury among left-handed individuals.

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PURPOSE: To determine the prevalence of intraosseous ganglion cysts in patients with unexplained wrist pain and evaluate the radiographic methods used for their detection. MATERIALS AND METHODS: Four hundred patients with unexplained wrist pain were prospectively examined. All patients underwent standard three-view radiography of the wrist. Patients with cystic areas on conventional radiographs underwent further examination with bone scanning. Ultimately, 17 patients whose bone scans demonstrated increased radiotracer uptake that localized to a particular carpal bone underwent magnetic resonance (MR) imaging. RESULTS: Of these 17 patients, intraosseous ganglion cysts were diagnosed in 15. Some of these ganglia were occult on conventional radiographs and were detected only at bone scanning and MR imaging. CONCLUSION: Intraosseous ganglion cysts in the wrist are more common than previously reported. In some patients, bone scanning, conventional radiography, and/or MR imaging will aid surgical resection that could provide symptomatic relief of unexplained wrist pain.

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For more than 80 years, surgeons have staged an unsuccessful search for a universally acceptable treatment for Kienböck's disease. It is our contention that no single treatment will be universally successful. Treatment choice must be based on a number of variables, including the experience of the surgeon, the desires and activity level of the patient, the anatomic variation of the ulna, and most importantly, on the stage of the disease. In the early stages, efforts should be made to salvage the lunate and prevent loss of normal architecture. In the later stages, efforts should be made to restore that architecture. In end stage, normal architecture must be sacrificed to restore function. Currently we recommend immobilization with possible equalization procedures for patients with ulnar-minus variance and stage I disease. In a patient with stage I disease and ulnar-positive variance, we recommend immobilization with consideration for a revascularization procedure. For stages II or IIIA disease with ulnar-minus variance, we attempt an equalization procedure. For stages II or IIIA disease with ulnar-positive variance, we recommend revascularization as performed by Hori. In stage IIIB disease, we prefer a triscaphe fusion to restore carpal stability and prevent further degeneration. In stage IV disease, proximal row carpectomy or wrist arthrodesis is indicated.

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Passage of a flexible catheter into a septic flexor tendon sheath can be difficult and time consuming because of the catheter's pliability. This article discusses a technique for converting the flexible catheter into a semirigid stylet.

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Malrotation complicating intramedullary nailing of the femur must be recognized before healing occurs in the early postoperative period to obtain correction with the least possible effort. A 20-year-old man with more than 40 degrees of excessive external rotation required careful evaluation and demonstrated the value of computed axial tomography (CT scan) followed by derotation.

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The reported incidence of implant failure following reamed intramedullary tibial fixation is low. When necessary, retrieval of failed tibial nail segments is best performed in a closed fashion in order to avoid the delayed healing and increased risk of infection that may result from exposure of the tibial fracture site. A method to facilitate closed removal of the distal segment of a failed tibial nail is described.

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