Neural injuries associated with supracondylar fractures of the humerus in children.

A retrospective review of displaced extension-type supracondylar fractures of the humerus in 101 children who were seen consecutively revealed eighteen associated neural injuries in thirteen children. Nine of the neural injuries in eight patients spontaneously resolved at a mean of 2.5 months (range, 1.5 to five months) after injury. The remaining nine lesions in five patients were explored at a mean of 7.5 months (range, five to fourteen months) after injury, because clinical and electromyographic studies showed no return of function. Neurolysis was performed on eight of the nerves that were explored (in five patients), and the remaining radial nerve was found to be completely lacerated and needed nerve-grafting. The length of follow-up after neurolysis averaged twenty-five months (range, thirteen to forty-four months). All five patients had functional recovery, as documented by range-of-motion, grip-strength and lateral pinch-strength, and von Frey and two-point-discrimination sensory testing. The patient who had had nerve-grafting never recovered neural function, and tendon transfers were needed. We concluded that observation and supportive therapy is the preferred initial approach for children who have a neural injury associated with a closed, displaced supracondylar fracture of the humerus. However, if there is no clinical or electromyographic evidence of return of neural function at five months after injury, exploration and neurolysis should be performed. If the nerve is in continuity, the prognosis after neurolysis is excellent.

Lyme arthritis in children. An orthopaedic perspective.

The cases of forty-three children with clinical and serological evidence of Lyme arthritis that was diagnosed between August 1983 and July 1985 were evaluated. The mean length of follow-up was twenty months, with a range of five to thirty months. All of the children lived in or had visited an area where the disease was known to be endemic. Arthritis was the presenting feature in more than half of the children, and half of the children had initially consulted an orthopaedic surgeon, none of whom made the correct diagnosis. Only twenty patients had a history of erythema chronicum migrans, the characteristic rash that precedes the arthritis, and for only nineteen children was there any recollection of having been bitten by a tick. Three patients had Bell palsy and one had a popliteal cyst in conjunction with the arthritis. All of the patients had oligoarticular involvement. The knee was involved in all but two patients. Recurrent attacks of synovitis were common. Effusion was the only radiographic abnormality that was observed, and it was found in thirty-two patients. The sedimentation rate was elevated in thirty of thirty-six patients. Immunofluorescent serology for Lyme disease, which is sensitive and specific, was uniformly positive. Of thirty-three patients who were treated with oral administration of penicillin or tetracycline alone, thirty-one responded, while two patients who had recurrent attacks of the disease responded to parenteral administration of antibiotics. The remaining ten patients responded to combinations of orally and parenterally administered antibiotics. Longer follow-up is needed to further document the apparently low rate of relapse after antibiotic therapy in this young population.

Treating fractures of the distal radius with arthroscopic assistance.

The role and technique of arthroscopy when used in the treatment of fractures of he distal radius are reviewed. Arthroscopy, if properly modified, assists in the evaluation and reduction of displaced intra-articular fractures of the distal radius in treating associated injuries within the carpus. Technical details important to the successful use of this technique are discussed. Favorable outcomes have been reported after the use of this technique for the reduction of displaced intra-articular fractures of the distal radius.

Arthroscopic reduction and internal fixation of distal radius fractures.

Despite recent advances in the treatment of complex distal radius fractures, problems of stiffness, carpal instability, and posttraumatic arthritis remain in a significant number of cases. Associated soft-tissue and ligamentous injuries are being recognized with increasing frequency. Arthroscopic reduction and internal fixation not only allow for anatomic reduction of the distal radius fracture with minimal surgical trauma, but provides a valid diagnostic and treatment alternative for the often missed associated injuries.

Mason type II radial head fractures: operative versus nonoperative treatment.

The most appropriate treatment of Mason type II radial head fractures remains controversial. Recommended treatment has included closed reduction and immobilization, resection, or open reduction and internal fixation. The cases of 29 Mason type II radial head fractures treated at Naval Hospital Oakland from 1983 to 1989 were identified. Twenty-six or 90% were available for detailed follow-up. All cases underwent standardized elbow evaluations and results were compared using an elbow score based on a 100-point scale. The parameters evaluated were pain, motion, elbow and grip strength, and function in activities of daily living. In addition, injury and follow-up radiographs were analyzed. Mean follow-up was 18 months. There were 10 cases treated by open reduction and internal fixation and 16 cases treated by closed means. At final follow-up, the operatively treated group had a mean elbow score of 92 and 90% good/excellent results. The nonoperatively treated group had a mean elbow score of 77 and 44% good/excellent results. This difference was statistically significant (p less than 0.01). Radiographic analysis revealed a higher incidence of articular depression, displacement, and joint narrowing in the nonoperatively treated group. We conclude that displaced radial head fractures treated nonoperatively have a higher incidence of pain, functional limitations, loss of strength, and radiographic evidence of arthritis when compared to those treated by open reduction and internal fixation.

Intra-articular fractures of the distal aspect of the radius.

Intra-articular distal radius fractures are a heterogeneous group of injuries with different fracture patterns. The existing classification systems are helpful for describing the fractures but not for assessing their stability or for deciding which surgical approach to use. Patients who have a fracture with at least 1.0 mm of displacement of the articular surface may benefit from open surgical treatment. Improved diagnostic imaging with CT is helpful for fracture classification and surgical planning. The options for surgical treatment include limited open reduction and internal fixation, arthroscopically assisted internal fixation, and open reduction and internal fixation. The surgical approach is determined on the basis of the initial displacement of the fracture. Patients who have a displaced fracture of the volar rim may benefit from a volar approach; those who have a dorsally displaced fracture, from a dorsal approach; and those who have an impacted fracture such as a die-punch fracture, from a dorsal approach that provides better visualization of the articular surface. The long-term functional outcome is determined in part by the severity of the fracture as defined by the amount of comminution, the initial severity of displacement, and the number of fracture fragments. The accuracy of the reconstruction of the articular surface, with the goal of establishing congruency to within 1.0 mm, is also important in order to minimize the risk of late osteoarthrosis. Of all of the extra-articular parameters, restoration of the length of the radius is the most important for enhancing recovery of motion and grip strength and for preventing problems involving the distal radioulnar joint--the so-called forgotten joint in distal radial fractures.

A complex free toe transfer after a reverse radial forearm flap.

A case is reported of the difficulties associated with late free toe transfer for thumb reconstruction after an initial reverse radial forearm flap.

Repeat Russe bone grafting after failed bone graft surgery for scaphoid non-union.

We report the long-term outcome of repeat Russe bone grafting after failure of a previous Russe graft for scaphoid non-union. 15 patients were followed for a mean of 71 months after their last surgical procedure. 11 patients had undergone a single previous Russe graft and four patients had two previous graft attempts. Internal fixation was used in only three patients. Eight out of 15 (53%) patients achieved union after a single repeat graft and one out of four united after a third attempt. When union was achieved, range of motion was unchanged, grip strength was increased 10% and pain was slight to none, allowing return to full employment in seven out of the nine patients. All patients who did not achieve union have either undergone a salvage procedure or are contemplating one. Based on the literature and our relatively low rate of union without internal fixation (53%), we recommmend supplementary internal fixation if repeat Russe bone grafting is undertaken. When union is achieved, satisfactory results can be expected.

Arthroscopic surgery of the knee on the U.S. Naval Hospital Ships during Operation Desert Shield.

Between September 1990 and January 1991, while deployed to the Persian Gulf for Operation Desert Shield, 118 patients underwent arthroscopic surgery of the knee on the U.S. Naval Hospital Ships USNS Mercy and USNS Comfort. There were 113 men and 5 women, with an average age of 28 years (range, 19-59 years). The most common findings at the time of arthroscopy were meniscus tears (53%), anterior cruciate ligament tears (29%), and normal arthroscopic examinations (9%). There were three complications, two hemarthroses and one superficial portal site infection. Seventy patients (59%) were able to be returned to duty at an average of 6 days post-operatively, obviating the need to evacuate these patients out of the Middle East theater to Europe or the United States, thus avoiding additional delay, expense, and loss of the service member to his military unit.

Complications of wrist arthroscopy.

Wrist arthroscopy has become an essential tool in the evaluation and treatment of a variety of wrist injuries and disease processes. As such, an understanding of complications related to wrist arthroscopy is critical to overall outcome. Complications are based on the unique anatomy of the wrist, portal locations, surgical technique, and type of procedure performed. This article describes techniques that may decrease the likelihood of each of these complications.

The role of arthroscopy in evaluating and treating trapeziometacarpal disease.

Thumb trapeziometacarpal arthroscopy offers unique opportunities for improving evaluation and treatment in patients with basal joint disease. For patients with early disease, arthroscopic synovectomy and electrothermal shrinkage of the capsule can provide symptomatic improvement. For patients with more advanced disease, arthroscopic hemitrapeziectomy and complete trapeziectomy can be performed, combined with electrothermal shrinkage of the anterior oblique ligament. This article reviews the surgical technique and the early follow up of this rapidly advancing, minimally invasive technique for treatment of trapeziometacarpal disease.

Proximal row carpectomy for the treatment of scaphoid nonunion.

Nonunion of the scaphoid bone may occur even with early diagnosis of fracture and modern internal fixation techniques. A pattern of degenerative instability termed scaphoid nonunion advanced collapse may lead to collapse of the carpus with irreversible articular damage initially isolated to the radiostyloid joint. Proximal row carpectomy (PRC), which removes the intercalary proximal row and creates a radiocapitate articulation, is a motion preserving salvage procedure which unloads the areas of articular pathology, and creates a new articulation that allows motion and is able to bear compressive forces over time. Although results of PRC specifically for scaphoid nonunion are clearly not reported in the article, several studies demonstrate that PRC provides a pain relieving and motion-sparing salvage option particularly suited for this condition.

Complications of common carpal injuries.

Interest in the diagnosis and treatment of common disorders of the carpus has intensified in recent years. Although newer nonoperative and surgical procedures have developed to improve outcome, complications and their treatment remain a challenging problem. To address complications of the more common carpal injuries, we have chosen fractures of the scaphoid, scapholunate ligament injuries, carpal fracture dislocations, and fractures of the hook of the hamate for discussion.

Complications of flexor tendon injuries.

Despite the many advances in the surgical and rehabilitative management of flexor tendon injuries, problems of adhesion, contracture, and rupture continue to limit the restoration of function in a significant number of cases. This article reviews the most frequent complications after flexor tendon injuries. The treatment options for these problems, including the authors' methods of choice, are discussed.

The Mount Sinai Hospital Library, 1883 to 1970.

A history of the Mount Sinai Hospital Library in New York City from its inception in 1883 to 1970 is presented. From its modest beginnings the growth and development of the library is reviewed through eight decades. The paper reports the library's expanded role in the Mount Sinai School of Medicine of the City University of New York.

The effect of ice application versus controlled cold therapy on skin temperature when used with postoperative bulky hand and wrist dressings: a preliminary study.

Skin temperature of the hands of 12 volunteers was monitored. The hands were placed in bulky dressings and treated with a standard ice bag (group I) or a new cooling blanket (group II). The contralateral hands served as controls. The mean difference in skin temperatures between group I and controls was 1.5 degrees F, while the difference between group II and controls was 13 degrees F. Temperatures of the controls did not decrease with time. Newer cooling devices appear to be more efficacious than standard ice bags in accurately and significantly lowering skin temperature when used with traditional bulky hand dressings.

Revision of the ununited one-bone forearm.

Between 1975 and 1995, 7 patients were surgically treated for persistent forearm pain following previously unsuccessful attempts of constructing a radioulnar synostosis using interosseous bone grafting with either cross screw or pin fixation. These prior reconstructive procedures were salvage operations to address symptomatic radioulnar instability. The time interval between index operation and revision surgery was a mean of 12.6 months (range, 4-36 months). The postoperative follow-up period averaged 29.7 months (range, 11-61 months). To address these failed radioulnar arthrodeses, plate osteosynthesis and aggressive bone grafting were used in 5 of 7 patients (group 1) (4 with autologous graft and 1 with demineralized bone matrix). Union was achieved in all 5 patients after a single revision operation. Radiographic evidence of solid union was seen at approximately 4 months. In the remaining 2 patients (group 2), revision synostosis procedures were performed; these involved local bone grafting and repeat transverse screw fixation in 1 patient and iliac crest bone grafting alone in the other. One of these 2 patients progressed to union; the other had a persistent symptomatic fibrous union. The 5 patients in group 1 reported symptomatic relief, while the 2 patients in group 2 were dissatisfied. There were no postoperative complications in our series. Based on our findings, we advocate abundant bone grafting and plating for rigid internal fixation in failed radioulnar synostosis procedures.

Reconstruction of the scapholunate ligament in a cadaver model using a bone-ligament-bone autograft from the foot.

This study is an investigation of a new procedure in which the scapholunate interosseous ligament (SLIL) is reconstructed using a bone-ligament-bone autograft from the foot. After investigation, the dorsal medial portion of the navicular-first cuneiform ligament (NFCL) was chosen for testing as a potential donor since it is similar in length and thickness to the SLIL and it is easily harvested with minimal potential donor site morbidity. Eight SLILs and NFCLs were harvested from fresh-frozen cadavers. Biomechanical extensometry testing was performed using an Instron 1000 machine. A 5-mm-wide central portion of the NFCL was tested since this width was compatible with the technical aspects of reconstructing the SLIL. Both ligaments were tested for elastic properties, including stiffness, load to failure, and deformation to failure. Mean length of the NFCL was 7.6 mm (range, 5.5-8.5 mm). Stiffness of the NFCL was 10.6 x 10(5) Nm (range, 8.0-13.0 Nm) compared with 14.4 x 10(5) Nm for the SLIL (range, 10.0-19.5 Nm). Peak load to failure for the NFCL was 1,980 N (range, 1,530-2,940 N) compared with 2,940 N for the SLIL (range, 1,780-4,050 N). Total elongation to failure for the NFCL was 2.50 mm (range, 1.7-3.2 mm) compared with 3.2 mm for the SLIL (range, 2.1-5.2 mm). Thus, the biomechanical characteristics of the NFCL were found to be very similar to those of the SLIL. Having established the biomechanical similarities of the 2 ligaments, we are currently using the NFCL to reconstruct the sectioned SLIL in a fresh-frozen cadaver model. Early results suggest that this procedure is feasible for restoration of normal kinematics of the wrist.