Despite technical advances in implant material, design, and instrumentation, plate fixation of metacarpal fractures remains fraught with complications and unsatisfactory results.

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.

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The results of this study confirm that a high patient satisfaction can be achieved for arthroscopic treatment of occult dorsal wrist ganglia, which seem especially amenable for arthroscopic treatment. Furthermore, the results suggest that arthroscopic resection of a dorsal capsular window can be indicated if the complaints and the clinical findings are typical for dorsal wrist ganglion, even though MRI findings may be negative.

Two hundred and seventy-three patients with carpal tunnel syndrome without advanced neurophysiological changes (distal motor latency below 11 ms) were randomized to treatment by open carpal tunnel release with, or without, epineurotomy. Patients were examined clinically and by nerve conduction studies preoperatively and at 3, 6 and 12 months postoperatively. We found no statistically significant difference between simple decompression and decompression combined with epineurotomy with regard to either the clinical or the neurophysiological outcome.

Complex regional pain syndrome type I (CRPS type I)--formerly termed Sudeck's atrophy or reflex sympathetic dystrophy (RSD)--causes chronic, poorly controllable pain, autonomic, sensorimotor disorders,and serious trophic alterations in the later stages. It develops in the distal extremities mostly after minimal trauma or surgical intervention and rarely spontaneously. The severity of symptoms is disproportionate to the causative event. The latest scientific findings show that the previously called reflex sympathetic dystrophy (RSD), which was supposed to be a result of a hyperreactive autonomic nervous system,is a very complex syndrome that occurs on different integration levels of the nervous system. Sympathetically maintained pain (SMP) may be facultatively characteristic, but is not to be misunderstood as an underlying mechanism. A neurogenic inflammation reaction has recently been discussed, just as had been postulated by Paul Sudeck long before. That was the reason why the International Association for the Study of Pain (ISAP) introduced the more descriptive term "complex regional pain syndrome" (CRPS) type I in 1994. Due to the complexity of the process necessitating qualified knowledge, it is important to immediately refer patients to a specialized pain OPD or clinic. The diagnosis of CRPS type I is based upon a carefully taken case history and a clinical examination by an experienced practitioner. Imaging diagnostic tools and laboratory findings are of no or only low predicative value. The question of whether SMP exists after diagnosing CRPS type I is eminent for therapy planning. Therefore, diagnostic regional anesthetics are still important in spite of their uncertain prognostic relevance. Physical therapy, occupational therapy, medical treatment, and psychotherapy play an important role in the primary treatment of CRPS type I as noninvasive procedures. Despite heavy criticism, invasive sympathetic block, subsequent to adequate diagnostics, is an important part of the therapeutic concept. A multimodal therapeutic concept, which includes all available possibilities, is absolutely necessary to avoid grave permanent disabilities caused by insufficient or failed therapy. Nevertheless, already established as well as new treatment modalities have to be critically observed by further randomized, prospective control trials.

Malunions are fractured bones that have healed in pathological positions. This leads to nonphysiological load transfer. Clinical symptoms at the ankle may include swelling, pain and impaired function. Lateral, posterolateral or posteromedial subluxation of the talus will be visible on the radiographs. Surgical correction may be indicated if the malunion is symptomatic. Different osteotomies have been described, but the goal of surgery will always be the reduction and retention of the subluxed talus in an effort to recreate stable conditions. Eighty percent of patients show good results with significant pain reduction in mid-term follow-up studies. Ankle arthrodesis after corrective osteotomy is rarely necessary.

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