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OBJECTIVE: To determine whether magnetic resonance imaging [MRI] in planes of imaging parallel to the known course of the extrinsic radiocarpal ligaments of the wrist aids in the visualization of these structures. SUBJECTS AND METHODS: MRI was performed on 32 wrists: a single normal cadaveric wrist, 23 normal wrists in volunteers and 8 wrists in patients with known scapholunate dissociation and rotatory scaphoid subluxation. Proton-density and T2-weighted images were obtained in the sagittal plane and gradient recalled echo images in an oblique sagittal plane, selected to parallel the extrinsic radiocarpal ligaments. The images were interpreted by two musculoskeletal radiologists. Each of the six main extrinsic ligaments was assessed for visualization or nonvisualization, and the morphologic features of those visualized were documented. RESULTS: With the exception of the dorsal radioscaphoid ligament, the volar and dorsal extrinsic radiocarpal ligaments were all consistently visualized in the normal wrists. For the eight cases of scapholunate dissociation, MRI demonstrated underlying rupture or thickening of the volar radioscaphocapitate ligament in all wrists and of the dorsal radiolunate ligament in five. CONCLUSION: MRI in the true and oblique sagittal planes can consistently demonstrate the extrinsic radiocarpal ligaments of the wrist. With this technique, extrinsic ligamentous abnormality can be demonstrated in patients with scapholunate dissociation and rotatory scaphoid subluxation.

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A primary intraneural biphasic synovial sarcoma that arose within the common digital nerve of the hand is reported. The patient, a 16-year-old girl, presented with a small soft tissue mass that clinically and intraoperatively resembled a nerve sheath tumor. The diagnosis of synovial sarcoma was established on the basis of a typical light microscopic appearance and immunohistochemical staining profile. Intraneural biphasic synovial sarcoma resembles "glandular" peripheral nerve sheath tumor, because both are composed of a mixture of spindled mesenchymal cells with admixed glandular epithelial elements. The features allowing differentiation of these two unusual tumors of peripheral nerve are discussed.

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To determine the significance of arthrographic abnormalities in patients with unilateral wrist pain, the authors compared the prevalence and site of intra-articular ligament perforation in asymptomatic and symptomatic wrists of the same group of patients and correlated asymptomatic perforation with age, hand dominance and hand overuse. Thirty-seven patients (29 men and 8 women ranging in age from 19 to 61 years) who had unilateral wrist pain and positive arthrographic findings for the symptomatic wrist underwent radiocarpal arthrography of the asymptomatic wrist. Three radiologists blinded as to the clinical findings examined the images for perforation in the triangular fibrocartilage complex, the lunotriquetral ligament and the scapholunate ligament. Intra-articular ligament perforations were found in 33 (89%) of the 37 asymptomatic wrists. Seventeen (46%) of the 37 patients had symmetric sites of perforation in the two wrists. Perforation of the triangular fibrocartilage complex occurred in 22 (59%) and 19 (51%) of the symptomatic and asymptomatic wrists respectively, of the lunotriquetral ligament in 13 (35%) and 7 (19%) respectively and of the scapholunate ligament in 13 (35%) and 11 (30%) respectively. No significant correlation between asymptomatic perforation and age or hand overuse was found (chi 2 test, Fisher's exact test). The authors conclude that asymptomatic perforation is common, even in young patients, so ligament perforation is not necessarily the cause of wrist pain in patients with such pain. However, for patients with the appropriate clinical findings, arthrography can be used to confirm or exclude ligament perforation.

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The results of 20 consecutive cases of bone defects of the hand treated by curettage and implantation of demineralized bone powder compare well with a similarly matched retrospective group managed with autogenous grafts and curettage alone. Results revealed "excellent" (16 patients) or "good" bone healing (4 patients) in the bone powder group on independent radiographic evaluation. Bone bridging was noted at an average of 9.9 weeks. All defects healed without recurrence, resorption or refracture, with follow-up of 4 to 36 months. In the conventionally managed retrospective group there was a 25% failure rate necessitating re-operation. Demineralized bone powder provides a rapid, safe and effective method of management of bone defects of the hand.

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The advent of tourniquets employing digital technology has led to significant improvements in the safety and accuracy of surgical procedures performed with an occlusive cuff applied proximally on a limb. This article describes the evaluation of new cuffs used on fingers that may permit significantly lower pressures to be more safely and consistently employed. Our experimental studies would suggest that finger occlusion pressure is a function of cuff design, cuff width, finger circumference, and systolic blood pressure.

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Complications of peripheral nerve injury arising from the surgical treatment of carpal tunnel syndrome are not uncommon. No documented report of the association of ulnar nerve injury with carpal tunnel decompression has been found. This case-study describes partial laceration of the ulnar nerve as a complication of carpal tunnel surgery and reviews the literature on this subject.

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A case of monostotic fibrous dysplasia of a long bone of the hand is reported. There has been only one similar case recorded, though it is not uncommon in other long bones. The diagnosis was proved by histology, and the tumour treated by subperiosteal excision. There has been no recurrence after 31 months, though in similar cases excision including the periosteum has been advised to reduce the likelihood of recurrence.

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Preventing the deformities of rotation and shortening is essential in the treatment of metacarpal fractures. Maintenance of accurate reduction is often difficult to achieve by cast immobilization or by the more sophisticated techniques that use plates and screws. During a four-year period, 92 of 290 metacarpal fractures were treated by open reduction and internal fixation. Of these, 21 were oblique and spiral fractures that were treated by cerclage wiring. The operation is performed with two to three lengths of No. 24 prestretched stainless steel wire that is tightened around the metacarpal shaft following fracture reduction. Mobilization of the hand is begun ten days following surgery, and full, unlimited use is permitted after six weeks. All 21 metacarpal fractures were followed up until the patient was ready to return to work, which occurred an average of seven weeks after surgery. Seventeen patients had no restriction of range of motion, with normal anatomic restoration of the metacarpal. Three patients lost 15 degrees of total active finger motion, and one had an extension lag of 10 degrees at the metacarpophalangeal joint.

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The trismus pseudocamptodactyly syndrome is a relatively rare condition with autosomal dominant inheritance, characterized by decreased ability to open the mouth (trismus), interphalangeal flexion deformity with wrist extension (pseudocamptodactyly), various foot deformities, and slightly less than normal stature. Five affected individuals from one family are reviewed and the orthopaedic aspects are described. The presence of trismus is emphasized for the orthopaedic surgeon, as it may lead to anaesthetic complications during the treatment of the musculoskeletal problems.

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Ulnar dimelia ("mirror hand") is a rare congenital anomaly of the upper extremity characterized by duplication of the ulna, absence of the radial ray, and polydactyly. A case report is presented in which the patient had seven triphalangeal digits arranged in a radial cluster of three and an ulnar cluster of four. Emphasis is placed on the technique of one-stage thumb reconstruction with the use of the principles described by Buck-Gramcko.

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Coccidioidomycosis is a rare disease and dissemination of the pulmonary infection occurs in less than 0.1% of cases. A case report of coccidioidal tenosynovitis in association with immunosuppressive chemotherapy is described. Recommended management includes both intravenous amphotericin B and surgical synovectomy.

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PIP: An updated definition of microsurgery includes the application of magnification techniques to basic surgical principles and the functional restoration of body structures by means of the direct union of parts or transfer of tissue using microsurgical techniques. Nylen performed the 1st surgery under magnification with the use of an operating microscope in Sweden in 1921. With the expanding scope of microsurgery, it becomes obvious that it is a surgical technique clinically applicable in every surgical specialty. The equipment for microscopy is microscopes, sutures, jeweler's forceps, needle holders, scissors, and coagulators. In microsurgery, all surgical movements have been reduced to a pinch mechanism between thumb and index. The instruments have been designed with this in mind and are characterized by small precision tips, light balanced proportions, pinch closure, and nonreflective surfaces. Long handled instruments are necessary for neurosurgery and gynecology due to the depth of the working field. The perfection of the microsurgery technique begins with extensive practice in the research laboratory. Clinical microsurgical reconstruction should be attempted only when competence has been achieved in the laboratory.^ieng

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