If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
and many present with dorsal synovitis derived from the radiocarpal joint, distal radioulnar joint and the extensor tenosynovium. Surgery is indicated if symptoms cannot be relieved by medical therapy or if there are tendon ruptures,
The extensor tendons and wrist joints are accessed by reflecting the extensor retinaculum, and it is widely recommended that the retinaculum be replaced deep to the extensor tendons to reduce the possibility of further tendon rupture.
Six dorsal compartments are delineated by vertical septae. Release of the retinaculum affects two biomechanical properties of the wrist: (i) the excursion distance of the extensor tendons; and (ii) the lateral displacement of the tendons. There is nearly 2 cm excursion of the extensor tendons as the wrist is moved from neutral to 60° of dorsiflexion, compared with less than 1 cm when the retinaculum is intact. The power of the extensor tendon is affected by its excursion: a 1 cm change in excursion results in an approximately 25% reduction in tension. There is no increase in bowstringing until the portion of the retinaculum overlying the wrist itself (1 cm wide) is released, particularly over the radiocarpal and ulnocarpal joints. Lateral displacement is most marked for those tendons without a direct line of pull, although this is less dependent on wrist position.
Wrist stiffness may prevent rheumatoid patients from compensating for the effects of bowstringing on tendon excursion and tension. It is, therefore, our practice to leave a narrow strip of retinaculum intact whenever possible (Fig. 2) , to prevent bowstringing and to obviate the need for reconstruction, particularly as the retinaculum may be flimsy in rheumatoid patients. This is possible in the majority of cases where access to tendons or the distal ulna is required, but it is not feasible when more extensive exposure of the radiocarpal or intercarpal joints is required. Leaving a 3–5 mm strip intact does not prevent a thorough tenosynovectomy or the removal of bone spikes such as Lister's tubercle. The remaining retinaculum can be placed deep to the tendons if required. It is often possible to preserve some or all of the vertical septae, thereby maintaining the normal tendon relationships and lines of pull (Fig. 3) .
Figure 2(A) Dorsal incision on the right wrist, with the distal part of the extensor retinaculum marked. (B) Proximal retinaculum reflected and a synovectomy performed. (C) Proximal retinaculum replaced deep to the finger extensors after excision of the ulnar head. (D) Postoperative view showing no bowstringing and good cosmesis.
Figure 3Right wrist after resection of Lister's tubercle, extensor indicis transfer to extensor pollicis longus and replacement of retinaculum beneath all tendons, showing preservation of normal tendon lines of pull.
of the proximal part of the retinaculum. Our previously undescribed technique maintains normal tendon anatomy and function. It is straightforward to perform, simpler than reconstructing a divided retinaculum and more mechanically efficient than previously described techniques.
Yours faithfully,
References
Rasker J.J.
Veldhuis E.F.M.
Huffstadt A.J.C.
Nienhuis R.L.F.
Excision of the ulnar head in patients with rheumatoid arthritis.
00019-5&id=gr1.jpg){kind=link}
00019-5&id=gr2.jpg){kind=link}
00019-5&id=gr3.jpg){kind=link}