Motorcyclist's thumb: carpometacarpal injuries of the thumb sustained in motorcycle crashes.

UNLABELLED: The purpose of this study was to investigate motorcycle crash thumb injury patterns. We hypothesized that ulnar collateral ligament injuries at the thumb metacarpophalangeal joint would be most common and there would be a side predilection due to the clutch and brake positions. Motorcyclist admissions following injury between 2002 and 2013 were reviewed, and phalangeal and metacarpal injuries treated acutely identified. Demographics, injury, and treatment characteristics were recorded. Association between laterality and injury type was assessed. Of 128 patients, 59 underwent acute treatment for thumb injuries. Eleven patients sustained thumb ulnar collateral ligament injuries; 27 sustained thumb carpometacarpal injuries. Most carpometacarpal injuries were fracture-dislocations (19/27). Thumb carpometacarpal injuries had no overall side predilection; ulnar collateral ligament injuries occurred more on the right. Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base. LEVEL OF EVIDENCE: Level IV.

Concurrent dorsal dislocations and fracture-dislocations of the index, long, ring, and small (second to fifth) carpometacarpal joints.

OBJECTIVE: To review the outcome of patients with concurrent dorsal dislocations and fracture-dislocations of the second, third, fourth, and fifth carpometacarpal (CMC) joints treated with open reduction and internal fixation (ORIF). DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS: Between 1991 and 1997, twelve multiply injured patients with the described CMC injury complex (one open injury) were treated with ORIF (eleven patients) or percutaneous wire fixation (one patient) by the same surgeon. INTERVENTION: Treatment consisted of ORIF with Kirschner wires followed by splints and immediate metacarpophalangeal and interphalangeal joint range of motion exercises. MAIN OUTCOME MEASUREMENTS: Grip strength, wrist and finger range of motion, pain, need for additional surgery, and return to work. RESULTS: Of the ten patients available for follow-up (mean, three years), all had been treated with ORIF (eight within forty-eight hours of injury and two had treatment delayed for four weeks because of delayed diagnosis and management of more serious injuries). Three patients had additional surgery (planned secondary second and third CMC arthrodeses). Grip strength of the operated hand in the five patients with JAMAR testing was 50 percent (n = 3), 75 percent (n = 1), and 90 percent (n = 1) of that in their contralateral hands. Five patients were pain-free, and five reported occasional, activity-related pain. The five patients who worked before the injury returned to their previous occupations (one with slightly modified duties). CONCLUSION: This is the largest series of patients with this CMC injury complex and the first report of open CMC dorsal dislocations and fracture-dislocations. Although early ORIF is suggested, delay of up to four weeks did not adversely affect results.

Proximal ulna shaft fractures and associated compartment syndromes.

In 1996, 6 (7%) of 84 ulna shaft fractures treated at our institution developed compartment syndrome. These 6 isolated, comminuted, proximal-third ulna fractures were secondary to low-velocity gunshot (5) or high-velocity blunt trauma (1). The 5 gunshot-induced fractures did not initially require immediate surgical intervention, but increasing compartment pressure prompted fasciotomy and open reduction and internal fixation. The blunt trauma fracture developed compartment syndrome while the patient awaited surgery; emergent fasciotomy and open reduction and internal fixation were performed. Three patients had vascular injury (interosseus system). The orthopedist must have a high index of suspicion for compartment syndrome in association with isolated, comminuted, proximal-third ulna fractures.

Exterior carpi radialis longus tendinoplasty for thumb basal joint arthritis.

Thumb carpometacarpal arthritis has been successfully treated with a combination of trapezium excision, ligament reconstruction, and tendon interposition (most commonly with the flexor carpi radialis [FCR] tendon). We describe a technique using the extensor carpi radialis longus (ECRL) tendon and show, through dissection of 36 cadaver hands, the close relationship between this tendon and the intermetacarpal ligament. Of 16 patients (19 hands) managed with this technique, 95% were satisfied at a mean follow-up of 42 months. We conclude that ligament reconstruction and ECRL tendon interposition constitute a viable treatment option for carpometacarpal joint arthritis, especially when the FCR tendon is unavailable or its use is undesirable.

Biomechanical evaluation of distal radius fracture stability.

OBJECTIVES/HYPOTHESES: (a) To determine the radiographic correlation between an artificially created dorsal comminution (via a wedge osteotomy) and dorsal tilt (clinical instability) and (b) to determine the efficacy of cast immobilization in maintaining reduction of the simulated fracture pattern as a predictor of successful treatment in the clinical setting. STUDY DESIGN: Biomechanical cadaveric study. SETTING: Level I trauma center. METHODS: In ten fresh cadaveric upper extremities, sequential dorsal wedge osteotomies (25, 50, and 75 percent of the distal radial diameter) were performed, each followed by measurement of tilt and radial inclination on posteroanterior and lateral radiographs before and after applying a load simulating the physiologic static forces of the forearm. In the last five specimens, the osteotomies were reduced and casted after the load application for each osteotomy, and radiographic measurements were again taken under loaded and unloaded conditions. RESULTS: In the uncasted loaded group (n = 10), average tilt changed from an initial 9 degrees palmar to 3 degrees palmar after the first osteotomy and became dorsally angulated (11 and 30 degrees) after the second and third osteotomies, respectively. Casting and loading resulted in a palmar tilt of 10, 6, and 3 degrees for the 25, 50, and 75 percent osteotomies, respectively. CONCLUSION: Increasing wedge osteotomies across the midline axis of the radius resulted in dorsal tilt and radial inclination changes representative of clinically unstable fractures that require more aggressive treatment protocols. However, in our experimental setting, casting maintained reduction of stable and unstable osteotomy patterns.

Anatomic variations of the musculocutaneous nerve in the arm.

To determine the course and anatomic relationships of the musculocutaneous nerve in the arm, we dissected 54 cadaver arms and measured the length of any interconnection between the musculocutaneous nerve and the median nerve (36% of dissections; mean, 1.77 cm) and the distance from the coracoid process to (1) the musculocutaneous nerve (mean, 0.46 cm distal); (2) the median nerve (mean, 1.91 cm distal); (3) the musculocutaneous nerve's entrance to and exit from the coracobrachialis muscle (mean, 4.99 cm and 7.55 cm, respectively); and (4) the musculocutaneous nerve's entrance into the biceps muscle (mean, 11.66 cm). The high percentage of anomalies found emphasizes the complexities and irregularities of this anatomic region with regard to surgical approaches.

Fractures of the fourth metacarpal.

OBJECTIVES: To determine (a) the degree of shortening associated with isolated fourth metacarpal fractures and the functional outcome after operative or nonoperative (protocol of casting and outrigger) treatment (clinical portion), and (b) the role of the deep metacarpal ligament in minimizing shortening after isolated fourth metacarpal osteotomies simulating clinical fracture (cadaveric portion). STUDY DESIGN: This two-part study included a retrospective clinical portion and a cadaveric investigation. METHODS: First, the records of twenty-four patients with isolated displaced oblique or spiral fourth metacarpal fractures without adjacent metacarpal fractures were retrospectively reviewed. The amounts of shortening after nonoperative (seventeen patients) and operative (seven patients) intervention were compared. Second, seven hands were studied to compare the length of intact fourth metacarpals to that after oblique osteotomies and after deep metacarpal ligament sectioning. The differences in shortening measurements were statistically analyzed using a paired t test. RESULTS: There was no significant difference in mean initial shortening (+/-SD) between operative and nonoperative patients (2.65 +/- 1.85 mm vs. 4.19 +/- 1.83 mm, respectively; p < 0.09; overall average shortening, 3.1 mm) or functional outcome. The cadaveric study documented the important role of the deep metacarpal ligament in minimizing fourth metacarpal shortening. Fourth metacarpals osteotomized with an intact deep metatarsal ligament had significantly less mean shortening (+/-SD) than those with a sectioned deep metacarpal ligament: 2.1 versus 5.8 mm, respectively (p < 0.001). CONCLUSIONS: In the absence of unreducible rotational malalignment, fourth metacarpal fractures may be adequately treated nonoperatively with a protocol of casting and outrigger.

Autografts from the foot for reconstruction of the scapholunate interosseous ligament.

A cadaveric study was undertaken to identify a potential autograft for use in repairing the ruptured scapholunate interosseous ligament. Three ligament complexes (the dorsal metatarsal ligament of the fourth and fifth metatarsals, a dorsal tarsometatarsal ligament, and the dorsal calcaneocuboid ligament) were chosen as autograft candidates. The scapholunate interosseous ligament and the three autograft candidates were harvested as bone-ligament-bone complexes from matched hands and feet of six fresh-frozen male cadavers (age, 51-68 years). The complexes were elongated using a servohydraulic testing machine at a constant grip-to-grip rate of 0.1 mm/s until failure. Stiffness and strength values were calculated and compared for each ligament complex. Analysis indicated that the stiffness values for the tarsometatarsal ligament and the scapholunate interosseous ligament were not statistically different, while such values for the other two autografts were significantly less. The strength values of all three autografts were significantly less than those of the scapholunate interosseous ligament. This study indicates that of the potential autografts tested, the tarsometatarsal ligament is biomechanically most similar to the intact scapholunate interosseous ligament.

Multiple ipsilateral dorsal metacarpophalangeal and proximal interphalangeal joint dislocations: a case report.

A 65-year-old male sustained dorsal dislocation of the long, ring, and small metacarpophalangeal joints and of the long and ring proximal interphalangeal joints. Immediate surgical intervention, including irrigation, debridement, and reduction, were performed. Early range of motion for all joints resulted in functional recovery.

Open half-pin insertion for distal radial fractures.

Twenty-two patients with unstable distal radial fractures were treated with external fixation using the open technique for half-pin insertion. Of the final study group of 19 patients, 7 (37%) demonstrated early pin-tract drainage, which resolved within 2 weeks after insertion. No pin loosening, pin change, pin breakage, infection, dorsal sensory nerve entrapment or irritation, tendon injury, or additional radial fracture occurred. Wrist range of motion in flexion/extension was 51/47 degrees, and the grip strength ratio (injured versus non-injured side) was approximately 61% on follow-up (average, 8 months). The open technique has proved efficacious in reducing complications associated with external fixation.

Combined Essex-Lopresti and radial shaft fractures: case report.

We present the case of a patient with multiple trauma, including a radial shaft fracture, a distal radioulnar joint dislocation, and a fracture-dislocation of the radial head. The combined open reduction of the radial shaft and head and the closed reduction of the distal radioulnar joint allowed early range of motion exercises and return to a functional level.

Carpal tunnel syndrome associated with histoplasmosis: a case report and literature review.

A case of localized Histoplasma capsulatum flexor tenosynovitis causing a carpal tunnel syndrome is presented. Carpal tunnel release, with tenosynovectomy, was performed followed by antifungal therapy. The symptoms did not recur. Tenosynovectomy followed by antifungal treatment is recommended.

Transscaphoid palmar lunate dislocation with scapholunate dissociation.

Concurrent scaphoid fractures with scapholunate ligament injuries have been felt to be mutually exclusive. A case with concurrent injuries is presented along with a discussion of the literature on perilunate injuries.

Open reduction and internal fixation of proximal interphalangeal joint fracture-subluxations.

Proximal interphalangeal (PIP) joint fracture-subluxations represent a small component of hyperextension injuries to the finger. Six unstable PIP fracture-subluxations that were not amenable to nonoperative treatment underwent open reduction and internal fixation. Among the patients, the technique of open reduction and internal fixation with temporary transarticular K-wire fixation and early protected range of motion has been found to result in a good range of motion with minimal complaints on follow-up.

Limited open-tendon-sheath irrigation in the treatment of pyogenic flexor tenosynovitis.

A retrospective review of 27 patients (28 fingers) with pyogenic flexor tenosynovitis, who were treated by a limited, open-tendon-sheath, intermittent-irrigation method that utilized a small pediatric feeding catheter, was conducted. The cases were subcategorized into three stages, based on the intraoperative appearance of the wound. Our results were 100% excellent in stage I; and 88.4% excellent, 5.8% good, and 5.8% fair in stage II. This method proved effective for the surgical management of pyogenic flexor tenosynovitis.

Type IV flexor digitorum profundus avulsion.

Flexor digitorum profundus avulsions, are well-documented injuries occasionally associated with a distal phalanx fragment. While the injury may involve primarily either tendon or bone, a rarely observed variant combines both tendon and bone avulsions. A type IV variant seen after two sequential injuries is described.