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Plastic and Reconstructive Surgery.... Nov 2018Guyon's syndrome results from a lesion of the ulnar nerve at the wrist caused by several conditions. The most common causes are ganglion, lipomas, fractures of the...
Guyon's syndrome results from a lesion of the ulnar nerve at the wrist caused by several conditions. The most common causes are ganglion, lipomas, fractures of the radius or pisiform bone, occupational trauma, neuritis, musculotendinous arch, and diseases of the ulnar artery. The clinical presentation varies with the site of lesion, as described by Sean and McClain in 1969, and can involve combined sensory and motor deficits, motor deficit alone, or sensory deficit alone. We present a case of bilateral Guyon's canal syndrome caused by a lipoma with Pacinian corpuscles on both wrists. Patient presented with sensory deficit as it is described by Shea and McClain with a negative electroneuromyography for ulnar compression. Articles correlating clinical presentation, etiology, and electrophysiological findings relating to ulnar nerve compression on the wrist are still uncommon in the literature.
PubMed: 30881781
DOI: 10.1097/GOX.0000000000001946 -
Acta Orthopaedica Belgica Dec 2018The aim is to report the long-term clinical results after pisiform excision in patients with refractory flexor carpi ulnaris (FCU) tendinopathy. We performed pisiform...
The aim is to report the long-term clinical results after pisiform excision in patients with refractory flexor carpi ulnaris (FCU) tendinopathy. We performed pisiform excision in 14 patients with recalcitrant FCU tendinopathy, who had failed conservative treatment. Nine patients were followed-up for more than 2 years. Pre-operative pain visual analog scale (VAS) was extracted from the electronic medical records. Post-operative symptoms and function were assessed with pain VAS, quick disabilities of arm, shoulder and hand (DASH) score, patient rated wrist evaluation (PRWE) score, and satisfaction VAS for surgery at the final follow-up. After the mean follow-up period of 6 years, all patients showed improvement in pain VAS (from 5.9 to 1.2). The post-operative scores of quick DASH and PRWE were 3.5 and 13.1, respectively. Satisfaction VAS score was 8.8 and all patients returned to their work. Excision of the pisiform bone improved symptoms in patients with refractory FCU tendinopathy.
Topics: Humans; Orthopedic Procedures; Patient Satisfaction; Pisiform Bone; Tendinopathy; Treatment Outcome
PubMed: 30879461
DOI: No ID Found -
Journal of Wrist Surgery Feb 2019Radiocarpal or midcarpal arthritis can occur simultaneously with arthritis of the distal radioulnar joint (DRUJ), leading to functional impairment of the wrist....
Radiocarpal or midcarpal arthritis can occur simultaneously with arthritis of the distal radioulnar joint (DRUJ), leading to functional impairment of the wrist. Treatment often involves wrist arthroplasty or arthrodesis, either with simultaneous or secondary procedures, addressing the DRUJ. Successful treatment of solitary DRUJ arthritis with DRUJ replacement has been reported. However, outcomes in patients with multiple prior wrist surgeries are lacking. Surgery in these wrists is challenging because surgical scarring and advanced bone deformities make implant positioning more difficult. Therefore, the aim of this study was to evaluate the outcomes in patients that underwent total wrist arthrodesis and DRUJ replacement after multiple prior wrist surgeries. We prospectively enrolled patients that underwent total wrist arthrodesis and replacement of the DRUJ, either simultaneously or during separate procedures from 1999 to 2012. We included 14 patients with a median age of 43 years (interquartile range [IQR]: 35-47). As objective outcomes range of motion, weight-bearing ability, grip strength, was measured. For the subjective outcomes, we used an analogue pain score and the disabilities of the arm shoulder and hand (DASH) scores. At a median follow-up of 5.6 years (IQR: 3.2-7.1). The average DRUJ range of motion and weight lifting ability significantly improved. As for the subjective evaluations, postoperative pain scores improved significantly, as did the DASH scores. Four of the patients had a postoperative complication, including infection and heterotopic ossification, of which two required reoperations. Additionally, 5 patients developed pisotriquetral arthritis requiring, pisiform excision, triquetrum excision, or the combination of both. Distal radioulnar joint replacement with a semiconstrained prosthesis was an effective method to restore the function of the wrist and forearm. As the surgical anatomy and soft tissue envelope were compromised in these patients, additional surgical exposure is necessary, adding to the complexity in these patients. No radiographic loosening This is a therapeutic level IV study.
PubMed: 30723603
DOI: 10.1055/s-0038-1670681 -
Medicine Nov 2018No surgical procedure perfectly treats advanced Kienböck disease. Although vascularized os pisiform transferring (VOPT) is one of the main therapeutic approaches,...
No surgical procedure perfectly treats advanced Kienböck disease. Although vascularized os pisiform transferring (VOPT) is one of the main therapeutic approaches, reports on long-term follow-up and case series for this technique are scarce.We collected postoperative results in 11 patients with advanced Kienböck disease who underwent VOPT between 1986 and 2001 in our Hospital. Follow-up durations ranged from 15 to 26 years.At the last follow-up, excellent and good results were found in 81.8% according to the Modified Green and O'Brien score. Postoperative imaging revealed significantly reduced pisiform bone; carpal height ratio and Nattrass index were decreased, while the radioscaphoid angle was increscent, compared with preoperative and mid-term follow-up results.The favorable long-term results demonstrated that VOPT is a dependable and durable procedure for the treatment of advanced Kienböck disease, with pain relief and functional improvement despite some radiographic findings such as wrist osteoarthritis occurrence.
Topics: Adult; Female; Follow-Up Studies; Humans; Male; Middle Aged; Osteonecrosis; Pisiform Bone; Postoperative Complications; Retrospective Studies; Time Factors; Young Adult
PubMed: 30508905
DOI: 10.1097/MD.0000000000013229 -
Journal of Wrist Surgery Nov 2018Pisiform excision and pisotriquetral arthrodesis are two surgical options for the treatment of pisotriquetral joint pain when conservative methods fail. However, it...
Pisiform excision and pisotriquetral arthrodesis are two surgical options for the treatment of pisotriquetral joint pain when conservative methods fail. However, it is unclear which option is best for patients who experience substantial, repetitive loading on their wrists and wish to preserve wrist flexibility and function. We present a case of bilateral ulnar-sided wrist pain related to the pisotriquetral joint in a 19-year-old collegiate diver. The pain was exacerbated by activities specific to this sport that requires wrist hyperextension, namely full weight-bearing on the hands (handstands), and has an impact on the hands and wrists upon water entry during dives due to direct palmar pressure. There were no radiographic signs of arthritis; however, there were bone marrow changes on magnetic resonance imaging (MRI). Management with rest, splinting, and corticosteroid injection failed to relieve the pain and precluded his ability to return to full-time diving. Treatment consisted of bilateral pisiform excision. Postoperatively, the patient returned to full-time competitive diving with resolution of his painful symptoms. Pisiform excision has been shown to have successful outcomes in terms of return to play for lower impact athletes (such as badminton) but has not been reported in athletes who experience a high degree of force repetitively (such as gymnasts or divers). There is one report of pisotriquetral arthrodesis in a young gymnast with suboptimal results. This case report demonstrates that pisiform excision is a successful treatment for elite athletes who experience repetitive, palmar force on hyperextended wrists and subsequently develop ulnar-sided wrist pain.
PubMed: 30349756
DOI: 10.1055/s-0038-1642047 -
Clinical Radiology Dec 2018To assess the diagnostic value of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) of diffusion tensor imaging (DTI) at several anatomical... (Meta-Analysis)
Meta-Analysis
AIM
To assess the diagnostic value of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) of diffusion tensor imaging (DTI) at several anatomical locations in patients with carpal tunnel syndrome (CTS) to explore the optimal parameters and measurement location.
MATERIALS AND METHODS
A search was conducted using the PubMed, EBSCO, Ovid, Web of Science, and Cochrane databases to identify articles relevant to this study published before September 2017. Studies were selected and included according to strict eligibility criteria. Mean differences (MD) and 95% confidence intervals (CIs) were used to compare FA and ADC values between CTS patients and healthy subjects. Potential publication bias was investigated.
RESULTS
Eleven studies involving 349 CTS wrists and 278 controls were selected for the meta-analysis. A notable MD: was found for lowered FA at the level of the pisiform bone for CTS versus controls (MD: -0.11, 95% confidence interval [CI]: -1.14 to -0.07, z=5.83, p<0.001). A higher ADC was found at the pisiform bone and hamate bone levels for CTS versus controls (P: MD: 0.15, 95% CI: 0.10 to 0.20, z=5.98, p<0.001, H: MD: 0.15; 95% CI: 0.09 to 0.21, z=4.67, p<0.001).
CONCLUSIONS
The meta-analysis demonstrated a significant FA reduction and ADC increase in CTS patients. This result supports the use of DTI parameters in differentiating CTS patients from health subjects. The anatomical site for FA at the pisiform and ADC at the pisiform and hamate levels were more accessible than other sites for the diagnosis of CTS patients.
Topics: Carpal Tunnel Syndrome; Diffusion Tensor Imaging; Humans; Median Nerve; Sensitivity and Specificity; Severity of Illness Index
PubMed: 30314809
DOI: 10.1016/j.crad.2018.08.015 -
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 -
Journal of Hand Therapy : Official... 2019Descriptive in situ cadaveric study.
STUDY DESIGN
Descriptive in situ cadaveric study.
INTRODUCTION
Performing accurately directed examination and treatment to the wrist requires clinicians to orient to carpal bone structures.
PURPOSE OF THE STUDY
To examine the anatomical relationships that exist within the wrist-hand complex and identify the accuracy of surface anatomy mapping strategies for localizing anatomical landmarks using a palmar approach.
METHODS
Twenty-three embalmed cadavers were dissected using standardized procedures. Metal markers were placed in the most prominent palmar landmark of key carpal structures. Relationships between the most prominent palpation landmarks and the carpal bones of interest were visualized using fluoroscopy.
RESULTS
The most successful methods of palmar capitate localization included the midpoint of a line from trapezium tubercle to pisiform; the midpoint of a line from scaphoid tubercle to hamate hook; or the intersection (cross) of these 2 diagonal lines, with successful capitate identification 100% (23/23) of the time. The most successful method for locating the lunate included the midpoint of a line from the radial styloid process to the ulnar styloid process, which identified the lunate in 100% (23/23) of cases.
DISCUSSION
The results of this cadaveric anatomical relationship study support the use of the midpoint of a line from pisiform to trapezium tubercle, the midpoint of a line from scaphoid tubercle to hamate hook, or a combination (cross) of these lines to locate the capitate from a palmar approach. In addition, the anatomical relationships examined in this study support the use of the midpoint of a line from the radial styloid process to ulnar styloid process to locate the lunate from a palmar approach. Knowledge of these anatomical relationships may improve the clinician's confidence in locating the capitate and lunate during intercarpal examination, special testing, and treatment.
CONCLUSION
Results of this study provide information of the anatomical relationships of the carpal bones from a palmar approach, giving clinicians a foundation for proper orientation to the carpal bones during clinical examination and intervention. Further research is needed to evaluate the reliability and accuracy of these methods for surface palpation on live patients.
Topics: Anatomic Landmarks; Cadaver; Capitate Bone; Carpal Bones; Female; Humans; Lunate Bone; Male; Palpation
PubMed: 30017416
DOI: 10.1016/j.jht.2018.02.002 -
Investigative Radiology Dec 2018The aim of this study was to describe the development of morphologic and diffusion tensor imaging sequences of peripheral nerves at 7 T, using carpal tunnel syndrome...
OBJECTIVES
The aim of this study was to describe the development of morphologic and diffusion tensor imaging sequences of peripheral nerves at 7 T, using carpal tunnel syndrome (CTS) as a model system of focal nerve injury.
MATERIALS AND METHODS
Morphologic images were acquired at 7 T using a balanced steady-state free precession sequence. Diffusion tensor imaging was performed using single-shot echo-planar imaging and readout-segmented echo-planar imaging sequences. Different acquisition and postprocessing methods were compared to describe the optimal analysis pipeline. Magnetic resonance imaging parameters including cross-sectional areas, signal intensity, fractional anisotropy (FA), as well as mean, axial, and radial diffusivity were compared between patients with CTS (n = 8) and healthy controls (n = 6) using analyses of covariance corrected for age (significance set at P < 0.05). Pearson correlations with Bonferroni correction were used to determine association of magnetic resonance imaging parameters with clinical measures (significance set at P < 0.01).
RESULTS
The 7 T acquisitions with high in-plane resolution (0.2 × 0.2mm) afforded detailed morphologic resolution of peripheral nerve fascicles. For diffusion tensor imaging, single-shot echo-planar imaging was more efficient than readout-segmented echo-planar imaging in terms of signal-to-noise ratio per unit scan time. Distortion artifacts were pronounced, but could be corrected during postprocessing. Registration of FA maps to the morphologic images was successful. The developed imaging and analysis pipeline identified lower median nerve FA (pisiform bone, 0.37 [SD 0.10]) and higher radial diffusivity (1.08 [0.20]) in patients with CTS compared with healthy controls (0.53 [0.06] and 0.78 [0.11], respectively, P < 0.047). Fractional anisotropy and radial diffusivity strongly correlated with patients' symptoms (r = -0.866 and 0.866, respectively, P = 0.005).
CONCLUSIONS
Our data demonstrate the feasibility of morphologic and diffusion peripheral nerve imaging at 7 T. Fractional anisotropy and radial diffusivity were found to be correlates of symptom severity.
Topics: Adult; Artifacts; Carpal Tunnel Syndrome; Diffusion Tensor Imaging; Echo-Planar Imaging; Feasibility Studies; Female; Humans; Image Processing, Computer-Assisted; Male; Middle Aged; Peripheral Nerves; Prospective Studies; Signal-To-Noise Ratio
PubMed: 29979328
DOI: 10.1097/RLI.0000000000000492 -
Acta Radiologica (Stockholm, Sweden :... Mar 2019Corticosteroid injections are a popular technique for carpal tunnel syndrome (CTS) treatment and are believed to provide rapid symptom relief.
Diffusion tensor imaging findings of the median nerve before and after carpal tunnel corticosteroid injection in patients with carpal tunnel syndrome: a preliminary study.
BACKGROUND
Corticosteroid injections are a popular technique for carpal tunnel syndrome (CTS) treatment and are believed to provide rapid symptom relief.
PURPOSE
To use magnetic resonance diffusion tensor imaging (MR-DTI) to determine the association between diffusion values of the median nerve (MN) at several anatomic locations and symptom relief in patients with CTS following corticosteroid injection.
MATERIAL AND METHODS
MR-DTI was performed on 15 wrists of 12 patients with CTS before and two weeks after ultrasound-guided corticosteroid injections. We recorded the patients' clinical data including sex, age, side of injection, satisfaction, and symptom relief. Satisfaction and symptom relief were rated using a Likert scale and the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) scale. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of the MN at the levels of the distal radioulnar joint (DRUJ), pisiform bone, and hamate bone were determined.
RESULTS
All patients had ≥50% satisfaction on the injection side. In comparison with baseline values, post-injection ADC was significantly lower ( P = 0.001) but FA was not significantly higher ( P = 0.11) at the pisiform bone level on the injected wrists. At the DRUJ and hamate bone levels, no obvious inter-scan change in FA and ADC ( P > 0.05) was observed. The decrease in ADC at the pisiform bone level strongly correlated with the decrease in BCTQ scores (r = 0.628; P = 0.012).
CONCLUSION
Symptom relief in patients with CTS receiving corticosteroid injection is related to the change in ADC of the median nerve at the level of the pisiform bone, as determined using MR-DTI.
Topics: Adrenal Cortex Hormones; Adult; Aged; Anisotropy; Carpal Tunnel Syndrome; Diffusion Tensor Imaging; Female; Humans; Injections; Male; Median Nerve; Middle Aged; Pain Measurement; Patient Satisfaction; Surveys and Questionnaires; Treatment Outcome; Ultrasonography, Interventional
PubMed: 29979105
DOI: 10.1177/0284185118784977