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Hand (New York, N.Y.) Jan 2020Increasing severity of carpal tunnel syndrome (CTS), as graded by nerve conduction studies (NCS), has been demonstrated to predict the speed and completeness of...
Increasing severity of carpal tunnel syndrome (CTS), as graded by nerve conduction studies (NCS), has been demonstrated to predict the speed and completeness of recovery after carpal tunnel release (CTR). The purpose of this study is to compare the cross-sectional area (CSA) of the median nerve in patients with severe and nonsevere CTS as defined by NCS. Ultrasound CSA measurements were taken at the carpal tunnel inlet at the level of the pisiform bone by a hand fellowship-trained orthopedic surgeon. Severe CTS on NCS was defined as no response for the distal motor latency (DML) and/or distal sensory latency (DSL). A total of 274 wrists were enrolled in the study. The median age was 51 years (range: 18-90 years), and 72.6% of wrists were from female patients. CSA of median nerve and age were comparatively the best predictors of severity using a linear regression model and receiver operator curves. Using cutoff of 12 mm for severe CTS, the sensitivity and specificity are 37.5% and 81.9%, respectively. Ultrasound can be used to grade severity in younger patients (<65 years) with a CTS-6 score of >12.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Carpal Tunnel Syndrome; Electrodiagnosis; Female; Humans; Linear Models; Male; Median Nerve; Middle Aged; Neural Conduction; Pisiform Bone; ROC Curve; Reference Values; Reproducibility of Results; Sensitivity and Specificity; Severity of Illness Index; Ultrasonography; Wrist; Young Adult
PubMed: 30027757
DOI: 10.1177/1558944718788642 -
Hand Clinics Aug 2019Vascularized bone flaps (VBFs) improve union rates for scaphoid nonunions compared with nonvascularized grafts. Volar VBFs are indicated in cases of scaphoid nonunion... (Review)
Review
Vascularized bone flaps (VBFs) improve union rates for scaphoid nonunions compared with nonvascularized grafts. Volar VBFs are indicated in cases of scaphoid nonunion with avascular necrosis and/or humpback deformity. Four volar VBFs are described in this article. The volar carpal artery and pronator quadratus VBFs are most commonly used. The pisiform VBF can be used for replacement of the proximal pole of the scaphoid; it is covered by articular cartilage. The ulna VBF has greater donor morbidity; the ulnar artery is harvested and a palpable donor site deformity results.
Topics: Cancellous Bone; Cortical Bone; Fracture Fixation, Internal; Fractures, Ununited; Humans; Muscle, Skeletal; Osteonecrosis; Pisiform Bone; Postoperative Care; Radius; Scaphoid Bone; Ulna
PubMed: 31178092
DOI: 10.1016/j.hcl.2019.03.012 -
The Journal of Hand Surgery... Dec 2021Aneurysmal bone cyst (ABC) is a benign expansile bone tumor without metastasis capability. Only 3-4% of ABCs occur in the hand and they mainly take place in metaphysis'... (Review)
Review
Aneurysmal bone cyst (ABC) is a benign expansile bone tumor without metastasis capability. Only 3-4% of ABCs occur in the hand and they mainly take place in metaphysis' of long bones like metacarpals or phalanges. Carpal ABCs have been reported as individual case reports in the literature due to rarity. A patient presented with pain in her right wrist. Magnetic resonance imaging revealed a well circumscribed one cm sized mass in the pisiform bone that resembled an aneurysmal bone cyst. Total pisiformectomy was performed. Treatment options are total excision or curettaging in ABCs. But rarity of these lesions may delay the diagnosis process for the inexperienced surgeon.
Topics: Bone Cysts, Aneurysmal; Bone Neoplasms; Female; Finger Phalanges; Humans; Magnetic Resonance Imaging; Pisiform Bone
PubMed: 34789109
DOI: 10.1142/S2424835521720231 -
Hand Surgery & Rehabilitation Sep 2021Scaphoid fracture can evolve into scaphoid nonunion leading to wrist arthritis. Vascularized bone flaps used to treat scaphoid nonunion are supplied by delicate, small,...
Scaphoid fracture can evolve into scaphoid nonunion leading to wrist arthritis. Vascularized bone flaps used to treat scaphoid nonunion are supplied by delicate, small, or short arteries that are not always reliable. The pisiform bone has never been considered as a possible treatment of scaphoid nonunion since the traditionally harvested pedicle is too short. This study aimed to characterize the vascularization of the pisiform with the goal of developing a method of harvesting it with a longer pedicle that can be used as a graft to treat scaphoid nonunion. A cadaver study on 30 upper limbs was done in two parts: firstly, we dissected 20 cadaver specimens and documented the pisiform's vascularization (size, length, and articular surface) as well as anatomical characteristics of the dorsal ulnar artery; secondly, we used 10 cadaver specimens to study an experimental surgical procedure in which a vascularized pisiform graft is used to treat an artificially created nonunion and confirm its feasibility. The pisiform artery originated from the dorsal ulnar artery in all 20 dissections. Its average length of 4.036cm could be increased by 11% by ligating the upstream collateral branches from the dorsal ulnar artery. The pedicled vascularized pisiform flap was grafted to the scaphoid in 10 experimental procedures performed on fresh cadavers. The vascularized pisiform graft consists of a reliable vascular pedicle and well vascularized multi-cortical bone with a cartilaginous surface. However, more studies are needed to confirm the feasibility of this flap as an alternative for treating unstable scaphoid nonunion.
Topics: Fractures, Bone; Fractures, Ununited; Humans; Pisiform Bone; Scaphoid Bone; Upper Extremity
PubMed: 33798753
DOI: 10.1016/j.hansur.2021.02.003 -
Zhongguo Xiu Fu Chong Jian Wai Ke Za... May 2020To provide anatomical basis for vascularized pisiform transfer in the treatment of advanced avascular necrosis of the lunate (Kienböck's disease) by studying its...
OBJECTIVE
To provide anatomical basis for vascularized pisiform transfer in the treatment of advanced avascular necrosis of the lunate (Kienböck's disease) by studying its morphology and blood supply pattern based on digital technique.
METHODS
Twelve adult fresh wrist joint specimens were selected and treated with gelatin-lead oxide solution from ulnar or radial artery. Then the three-dimensional (3D) images of the pisiform and lunate were reconstructed by micro-CT scanning and Mimics software. The morphologies of pisiform and lunate were observed and the longitudinal diameter, transverse diameter, and thickness of pisiform and lunate were measured. The main blood supply sources of pisiform were observed. The number, diameter, and distribution of nutrient foramina at proximal, distal, radial, and ulnar sides of pisiform were recorded. The anatomic parameters of the pedicles (branch of trunk of ulnar artery, carpal epithelial branch, descending branch of carpal epithelial branch, recurrent branch of deep palmar branch) were measured, including the outer diameter of pedicle initiation, distance of pedicle from pisiform, and distance of pedicle from lunate.
RESULTS
There were significant differences in the longitudinal and transverse diameters between pisiform and lunate ( =6.653, =0.000; =6.265, =0.000), but there was no significant difference in thickness ( = 1.269, =0.109). The distal, proximal, radial, and ulnar sides of pisiform had nutrient vessels. The nutrient foramina at proximal side were significantly more than that at distal side ( <0.05), but there was no significant difference in the diameter of nutrient foramina between different sides ( >0.05). The outer diameter of pedicle initiation of the recurrent branch of deep palmar branch was significantly smaller than the carpal epithelial branch and descending branch of carpal epithelial branch ( <0.05). There was no significant difference in the distance of pedicle from pisiform/lunate between branch of trunk of ulnar artery and recurrent branch of deep palmar branch ( >0.05), and between carpal epithelial branch and descending branch of carpal epithelial branch ( >0.05). But the differences between the other vascular pedicles were significant ( <0.05).
CONCLUSION
There are abundant nutrient vessels at the proximal and ulnar sides of pisiform, so excessive stripping of the proximal and ulnar soft tissues should be avoided during the vascularized pisiform transfer. It is feasible to treat advanced Kienböck's disease by pisiform transfer with the carpal epithelial branch of ulnar artery and the descending branch.
Topics: Adult; Carpal Bones; Feasibility Studies; Humans; Lunate Bone; Osteonecrosis; Ulnar Artery
PubMed: 32410427
DOI: 10.7507/1002-1892.201907128 -
Hand Surgery & Rehabilitation Oct 2023Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome.
OBJECTIVES
Fractures of carpal bones other than the scaphoid are rare in children. The aim of this study was to analyze results and identify risk factors for an unfavorable outcome.
MATERIAL AND METHODS
Children and adolescents up to the age of 16 years who sustained a carpal fracture other than in the scaphoid between 2004 and 2021 were reviewed in this single-center retrospective study.
RESULTS
In a series of 209 children and adolescents with carpal fractures, 22 had fractures other than the scaphoid. Mean age was 13 years (range 8-16) years, with a total of 41 fractures, with highest incidences for the capitate (10), trapezium (6), triquetrum (4) and pisiform (4). Twenty-nine of these 41 fractures were missed on initial X-ray. Non-displaced fractures were treated with a short arm spica cast including the thumb. Four patients were operated on for displacement fracture or carpometacarpal subluxation. All fractures united, and patients returned to full activities. At the final consultation at a median 14 months (range 6-89) post-injury, all patients with non-displaced fractures were free of symptoms, with excellent Mayo Wrist Scores (MWS). However, three patients with operated trapezium fractures developed early radiological signs of osteoarthritis, two of them with residual pain and MWS rated only good.
CONCLUSION
Non-displaced pediatric carpal fractures treated by forearm cast have excellent prognosis. Fractures of the trapezium with displacement or first carpometacarpal subluxation incur a risk of osteoarthritis despite anatomical reduction and internal fixation.
Topics: Adolescent; Humans; Child; Retrospective Studies; Fractures, Bone; Scaphoid Bone; Wrist; Wrist Injuries; Joint Dislocations; Hand Injuries; Osteoarthritis
PubMed: 37356568
DOI: 10.1016/j.hansur.2023.06.009 -
Journal of Plastic, Reconstructive &... Aug 2022Although good clinical results have been reported following lunate resection and vascularized os pisiform transfer for advanced stages of Kienböck's disease, the...
Although good clinical results have been reported following lunate resection and vascularized os pisiform transfer for advanced stages of Kienböck's disease, the occurrence of wrist osteoarthritis has been highlighted. We aimed to investigate the postoperative condition of the pisiform and the surrounding bones in patients who underwent surgery for advanced stages of Kienböck's disease using magnetic resonance imaging. We retrospectively reviewed the data of six patients (mean age, 45 years; Lichtman stage, IIIb) who underwent lunate resection and vascularized os pisiform transfer for advanced stages of Kienböck's disease and postoperative magnetic resonance imaging examination. We extracted clinical data on pre- and postoperative range of motion, grip strength, wrist pain, Hand20 and Lichtman's criteria, and pre- and postoperative radiographic and magnetic resonance imaging examinations. Bone marrow lesions in the transferred pisiform were found in five patients. Signal changes of bones around the transferred pisiform were found in these five patients; the greatest change was observed in the capitate bone in three patients. These signal changes were found in the opposite parts of the bones around the transferred pisiform. No patient exhibited signal changes in the transferred pisiform bone only. Wrist osteoarthritis after lunate resection and vascularized os pisiform transfer for advanced stages of Kienböck's disease is more likely to be attributed to the low congruency of the transferred pisiform and surrounding bones than to the compromised perfusion of the pisiform. Signal changes in the opposite bone parts around the transferred pisiform were confirmed in all patients with signal changes in the pisiform.
Topics: Humans; Lunate Bone; Magnetic Resonance Imaging; Middle Aged; Osteoarthritis; Osteonecrosis; Pisiform Bone; Retrospective Studies; Wrist Joint
PubMed: 35501258
DOI: 10.1016/j.bjps.2022.04.016 -
The Journal of Hand Surgery, European... Oct 2022
Topics: Carpal Bones; Child; Humans; Osteonecrosis; Pisiform Bone
PubMed: 35642533
DOI: 10.1177/17531934221101825 -
Cureus Jul 2023Background The purpose of the study was to provide a practical landmark for localizing the dorsal branch of the ulnar artery and nerve, to approach for microsurgical...
Background The purpose of the study was to provide a practical landmark for localizing the dorsal branch of the ulnar artery and nerve, to approach for microsurgical flaps, for harvesting nerve grafts and also to avoid these nerves during insertion of wrist arthroscopy portals. Material and methods Forty adult cadaveric upper limbs (20 right and 20 left) were dissected for localizing the dorsal branches of the ulnar artery and nerve. The ramification patterns of the nerve were mapped. The wrist arthroscopy portals are located radial and ulnar to the tendon of extensor carpi ulnaris at the level of the wrist joint, and their designated names are '6R & 6U', respectively. The distance of branches of the nerve from the 6U and 6R portals for wrist arthroscopy was recorded. Results The present study has delineated a subcutaneous dorsomedial triangular area in the distal forearm. The construction of this triangle uses palpable landmarks, i.e. pisiform bone, styloid process and subcutaneous border of the ulna. The measure of the sides of the triangle uses proportion rather than absolute measurements and hence is person specific. The dorsal branches of the ulnar nerve and artery are consistently given off in the triangle's upper third and middle third, respectively. Four branching patterns have been mapped, with one dominant pattern in 67.5% of limbs. In three-fourths of cases, one branch of the dorsal branch of the ulnar nerve consistently overlies the 6U portal and hence runs a higher risk of injury. Conclusion The study suggests more practical, accurate, reliable and consistent surface landmarks for the localization of the dorsal branch of the ulnar artery and nerve for reconstructive microsurgery for distal hand defects.
PubMed: 37593310
DOI: 10.7759/cureus.41981 -
Surgical and Radiologic Anatomy : SRA Sep 2015The aim of this study was to clarify the definition of the anterior wall of the ulnar tunnel and to reveal the topographical characteristics of the various components of...
PURPOSE
The aim of this study was to clarify the definition of the anterior wall of the ulnar tunnel and to reveal the topographical characteristics of the various components of the ulnar tunnel.
MATERIALS AND METHODS
Twenty-two forearms from 11 embalmed cadavers (7 males, 4 females; mean age, 67.8 years) were carefully dissected.
RESULTS
In all cases, the anterior wall of the ulnar tunnel comprised the hypothenar fascia, which originated from the tendon of the flexor carpi ulnaris muscle. The palmar carpal ligament, the distal extent of the antebrachial fascia, was located deep to the anterior wall and formed only the anterior boundary of the proximal hiatus of the ulnar tunnel. The hypothenar fascia was attached to the flexor retinaculum at 15.2 mm lateral to the pisiform bone. However, the palmar carpal ligament was attached to the flexor retinaculum just lateral to the ulnar artery; the distance between the attachment of the palmar carpal ligament and the pisiform bone was 8.7 mm. Anatomical variations potentially associated with ulnar nerve compression were observed. The accessory abductor digiti minimi muscle and the fibrous band crossing the ulnar nerve in the ulnar tunnel were found in 27 and 23 % of forearms, respectively.
CONCLUSION
A more detailed description of the anterior wall of the ulnar tunnel than was previously available is presented herein, and topographic and metric data regarding each structure of the tunnel are reported.
Topics: Aged; Cadaver; Dissection; Fascia; Female; Humans; Male; Middle Aged; Muscle, Skeletal; Ulnar Artery; Ulnar Nerve; Ulnar Nerve Compression Syndromes; Wrist Joint
PubMed: 25575670
DOI: 10.1007/s00276-014-1415-2