A Word in the Hand

June 2002


In This Issue:

 

Western Pennsylvania Hand and Trauma Center Performs the First Ulnar Head Implant in Pittsburgh

The distal radioulnar joint (DRUJ) is responsible for rotation of the forearm, moving the palm up and down. Disorders of the DRUJ can be extremely painful and give rise to arthritis and instability, which severely limit the capability of the hand and wrist. Complications from injury such as wrist fractures, or degenerative arthritis are common at this site. Inflammation may extend into adjacent extensor tendons, thereby resulting in extensor tenosynovitis. The positions of the radius and ulna can be affected so that there is a discrepancy with the distal ulna becoming more prominent. This may lead to additional extensor tendon irritation, with weakening or rupture of the tendon.

Conservative management may include splinting, therapy, anti-inflammatory medications, and cortisone injections. However, surgical treatment is recommended when symptoms persist and pain is unyielding. Resection of the distal ulna, also known as the Darrach procedure, is the most common surgical method. However, complications related to loss of the ulnar head include wrist instability, pain, weak grip strength, and limited rotation of the forearm.

For patients who suffer from painful disorders of the distal radioulnar joint, a new procedure is available. The uHead Ulnar Implant System was developed by Avanta Orthopaedics Corporation and received FDA approval in September 1998. It allows for replacement of the ulnar head while preserving the functional elements of the radioulnar and ulnocarpal structures. This results in a more stable joint complex that anatomically addresses the complex kinematic loading associated with hand and wrist motion.

The distal ulna prosthesis duplicates the normal anatomy of the distal ulna, which aligns anatomically with the sigmoid fossa of the distal radius and is isosymmetric with the anatomic center of rotation of the forearm. It provides for reattachment of the triangular fibrocartilage (TFCC), ECU subsheath, and ulnar collateral ligament complex to form a secure soft tissue pocket maintaining DRUJ stability.

M. Hopper, a 38-year old patient of Dr. Glenn Buterbaugh, was the first in Pittsburgh to receive the uHead implant. Mr. Hopper sustained his initial injury when he fell over the handlebars onto his outstretched hand while mountain biking. This resulted in a slightly fragmented fracture involving the distal radius with approximately 1/3 shaft dorsal displacement and palmar angulation. He also sustained an associated avulsion fracture of the ulnar styloid. After casting and physical therapy, he lost significant use of his hand. He was not able to turn a doorknob or the key in the ignition of a car. He subsequently fell rollerblading 5 years later, resulting in another intra-articular distal radius fracture. After the fracture healed, he continued to experience chronic swelling, pain and wrist instability which interfered with daily functions and activities including biking, tennis, and landscaping/gardening.

At 8 weeks post-op, Mr. Hopper states that he is happy with the uHead Implant Surgery. He rates his pain at a level of 0-2 on a scale of 0-10, with 10 being severe pain. He is encouraged by the results and looks forward to resuming his activities and completing his pilot’s license. He feels the operation is well worth it in order to resume doing the things he really enjoys.

 

Carpometacarpal Arthroplasty of the Thumb

Ligament reconstruction-tendon interposition for CMC osteoarthritis provides excellent pain relief and improvement of strength. However, therapy can be extensive and resumption of normal activity may take six months. Our technique minimizes the morbidity of surgery and allows early rehabilitation. 

We reviewed 42 CMC arthroplasties in 38 patients with osteoarthritis (average follow-up 2.2 years). Using a radial approach, the trapezium is exposed using a U-shaped, distally-based capsular flap. After trapezial resection, this flap is sewn to the FCR tendon with the thumb metacarpal suspended. Secondly, a dorsal cortical rim of trapezium is left intact as a spacer to prevent proximal metacarpal migration. In 36 thumbs, the palmaris longus was placed in the arthroplasty space. Six required no tendon graft. The FCR was not used for reconstruction. Finally, the EPB is transferred to the APL to correct metacarpal adduction. At two weeks postoperatively, patients begin therapy in a removable splint. Patients were evaluated for pain, motion, and strength. Proximal metacarpal migration was measured radiographically.

Pain relief was excellent in 41/42 thumbs. Thirty-eight were able to touch the thumb to the base of the small finger at an average of 3.8 months postoperatively. Thirty-three thumbs had a least 75% of pinch strength compared to the uninvolved side. Serial radiographs demonstrated proximal migration of 12%.

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The Benefits of Exercise

The benefits of exercise are vast. Many have reported improved sleep habits, reduction in stress levels, curbing of anxiety or depression symptoms, reduced risk of heart disease, and lower risk of developing diabetes. Regular exercise can increase muscle strength, improve balance, and increase bone density, thereby preventing osteoporosis. Strength training and moderate aerobic exercise can also reduce joint swelling and pain in arthritis sufferers.

Exercising with osteoarthritis is possible and may help to develop healthy articular cartilage on the joint surface. Reduced weight bearing activities, such as underwater walking or jogging, non-weight bearing activities, such as cycling with no resistance, and calisthenics are recommended.

Sports and exercise can be enjoyable activities, which also may result in injuries. Prevention is the best medicine. Always warm-up for 5-10 minutes before playing. It improves blood flow to the heart, increases muscle temperature, and makes muscles more flexible. Just as cold chewing gum won’t stretch, cold muscles won’t either and will be more prone to injury. Include some jumping jacks, walking in place, and slow gentle stretches. Stretching should not be painful.

 Wear protective gear. Drink plenty of fluids before, during and after play to maintain ideal hydration. Dehydration can lead to decreased concentration levels, decreased endurance, fatigue, increased clumsiness, and injury. Remember that alcohol and sports don’t mix. Also, have a first aid kit handy. 

Avoid playing when tired or in pain, and stretch after playing to reduce the risk of injuries happening. It will reduce muscle soreness and increase flexibility. Recovery from an injury can take weeks, months, and even years. Prompt treatment can often prevent a minor injury from becoming worse or causing permanent damage.

Many minor injuries can be treated effectively using the RICE plan.

Rest: it is best to stop activity and rest the injured body part, rather than “walk it off”.

Ice: Apply ice for 20-30 minutes on a regular basis for 24-72 hours to reduce pain and minimize inflammation.

Compression: Apply bandages to hold the ice pack in place, and wrap injured body part firmly to reduce swelling.

Elevation: elevate the injured body part as soon as possible to reduce fluid accumulation.

The goals of exercise are to improve flexibility and movement in joints and muscles, build strength and endurance, enhance oxygen delivery and improve your sense of well-being. No one is too old or too young to participate in some form of exercise. 

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Prevention Is The Best Way To Stay In The Game

Millions of golfers will hit the links as golf season moves into full swing. Many of those who play at least one round of golf per week will become injured or experience a health related problem requiring medical care. Injury prevention is the best way to stay in the game. 

As with any form of exercise, a proper warm-up is essential to increase blood circulation and stretch muscles used when golfing. This reduces the chance of injury and can actually strengthen your swing while improving overall performance in the game. Side steps, walking and arm circles are great warm-up exercises. Stretching should not be painful. It is important to hold stretches without bouncing. Stretching is just as important after your game to relieve tight muscles, improve flexibility, and prevent soreness.  

Nutrition is important when preparing for a game of golf. Eating properly will provide energy, endurance, strength, and alertness. Nutritionists recommend 60-70% carbohydrates, which include vegetables, pasta, grains and cereal. They will provide the necessary energy and eliminate low-blood sugar, which can lead to fatigue. Drink plenty of fluids before, during and after play to maintain ideal hydration. Dehydration can lead to decreased concentration levels, decreased endurance, fatigue, increased clumsiness, and injury. 

Golfers spend hours in the sun during each round of golf. It is important to always wear sweat proof sunscreen, hat and sunglasses with UV protection. Wrap-around sunglasses have been designed to keep out almost 100% of harmful rays.  

Wrist injuries are common among both professional and amateur golfers. They can be caused by trauma when hitting the ground during a swing or by overuse leading to inflammation.  

Tendonitis in the wrist is a frequent condition in which pain is caused by inflammation of the tendons either on the side of the wrist (flexor tendons) or on the back of the wrist (extensor tendons). Specifically, in DeQuervain’s Tendonitis, painful inflammation develops within the tendons along the thumb side of the wrist. Tendons which pass over the back of the wrist help the muscles which extend or straighten the fingers and thumb, as well as lift the hand at the wrist joint. The tendons run through compartments under a thick layer of fibers, known as the extensor retinaculum or dorsal compartment ligament. When inflammation occurs, the tendons may become swollen and constricted within the lubricated sheath which lines the dorsal compartment. This may be due to repetitive trauma or overuse of the wrist and hand, such as side-to-side movements. Pain can be felt while gripping an object and twisting the wrist. 

Patients usually present with swelling over the thumb side of the wrist. Motion is painful and worsens with use of the hand and thumb. Grasping and pinching are difficult. There also may be triggering of the thumb. A Finkelstein test is administered to make a definitive diagnosis of this disease. The patient flexes the thumb into the palm while making a fist. The wrist is then bent downwards. This is a very painful maneuver to a patient with DeQuervain’s tendonitis.  

Initial treatment is by immobilization with a thumb spica splint and/or anti-inflammatory medication. Injection of steroid and lidacaine into the inflamed area may also help to decrease the inflammation and reduce the symptoms. More than one injection may be necessary for relief. If the symptoms fail to respond to treatment, surgical release of the compartment is usually necessary and performed on an out-patient basis. An exercise program for the thumb and wrist is important. Most patients can expect resolution of symptoms within 2 to 4 weeks. 

The golf swing is always in the same motion, and thousands of golf swings can lead to tissue injury and inflammation. This translates into pain. It may subside during a rest from golf, but will likely return upon resuming golf if rehabilitation or strengthening exercises are not performed. Common sense and a good strengthening program can prevent many overuse injuries. If pain and swelling persist, it is important to seek medical care.  

At the Western Pennsylvania Hand and Trauma Center, we are dedicated to the treatment of all patients with the goal of returning the patient to work, sports, and daily activities with the highest possible level of function. Our certified hand therapists can recommend strengthening exercises and a rehabilitation program to meet each individual’s needs.  To make an appointment or for additional information, please call 724.933.3850 ext. 175.

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In The News...

Dr. Joseph E. Imbriglia was voted one of the Best Doctor's in America 2002 for Hand Surgery

Michael W. Bowman, M.D. was appointed to the Board of Directors of the American Orthopaedic Foot and Ankle Society in February 2002 for a term of three years.

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