Magnetic resonance imaging of the interosseous membrane of the forearm.

BACKGROUND: Diagnosis of damage to the interosseous membrane of the forearm after trauma is difficult. Patients with a proximal radial fracture and associated damage to the interosseous membrane may have wrist pain in association with subluxation or dislocation of the distal radioulnar joint. Accurate identification of injury to the interosseous membrane may allow better planning of surgical treatment. METHODS: T1 and T2-weighted magnetic resonance images that were made in the axial, sagittal, and coronal planes were used to evaluate the interosseous membrane in the forearms of cadavera, volunteers, and patients. The images were evaluated subjectively by two orthopaedic surgeons and a musculoskeletal radiologist. RESULTS: The interosseous membrane was most consistently visualized on the axial images. Axial T2-weighted images showed the interosseous membrane clearly. The addition of fat-suppression techniques allowed abnormalities to be identified more accurately. Fast-spin-echo techniques were used to obtain data quickly and accurately. CONCLUSIONS: The intact and disrupted interosseous membrane can be evaluated with use of magnetic resonance imaging. Axial T2-weighted fast-spin-echo images with fat suppression in the middle one-third of the forearm provide the most accurate information.

Neural anatomy of the human anterior cruciate ligament.

The histology of the anterior cruciate ligament was studied by a modified technique of the Gairns gold chloride stain for neural elements. Three morphological types of mechanoreceptors and free nerve-endings were identified: two of the slow-adapting Ruffini type and the third, a rapidly adapting Pacinian corpuscle. Rapidly adapting receptors signal motion and slow-adapting receptors subserve speed and acceleration. Free nerve-endings, which are responsible for pain, were also identified within the ligament. These neural elements comprise 1 per cent of the area of the anterior cruciate ligament.

Fractures of the femoral shaft treated by external fixation with the Wagner device.

The Wagner external skeletal-fixation system was used to treat twenty complex fractures involving the femur, and nineteen of the fractures healed. Chronic osteomyelitis did not develop in any of the patients.

Dural puncture using the lateral approach for chemonucleolysis.

The lateral approach for chemonucleolysis was developed to avoid dural puncture, which occurs with midline and posterolateral approaches. It is important to check for dural punctures during the procedure. If the dura is penetrated, a potential pathway is created for chymopapain to enter the subarachnoid space. Large doses of intrathecal chymopapain are highly toxic and small doses show a variable response. Because of the potential disastrous complications associated with intrathecal chymopapain, the chymopapain injection is contraindicated in the presence of a dural leak.

Safety and efficacy of chymopapain (Discase) in the treatment of sciatica due to a herniated nucleus pulposus. Results of a randomized, double-blind study.

A prospective, multiinstitutional, double-blind trial comparing the effect of chymopapain (Discase) vs. placebo (cysteine-edetate-iothalamate: CEI) for lumbar intervertebral disc rupture with sciatica was carried out on 173 patients, the largest such study reported to date. Patients were matched with respect to age, sex, physical habitus, and level of injection. The procedure was carried out under local anaesthesia. The success rate was superior in the chymopapain group regardless of the method used to assess outcome or the time over the first 6 months at which the two groups were compared: 71% vs. 45% if code breaks were analyzed at 6 months, and 67% vs. 44% if code breaks were defined as lost to follow-up. A single case of anaphylaxis and one case of septic discitis were the only serious complications noted. This study supports the role of chymopapain in the treatment of lumbar disc rupture with sciatica.

Plate fixation of the humeral shaft for acute fractures, with and without radial nerve injuries.

We report herein the results of operatively treating 44 consecutive acute fractures of the humeral shaft using plates for internal fixation. Ninety-seven percent (43 of 44) of the fractures healed after plate fixation at an average of 12 weeks. One short plate pulled out and required revision with a longer plate and bone grafting; this fracture also healed. Cancellous bone grafting successfully filled in cortical bone gaps. Range of motion of the shoulder and elbow were essentially normal. Plate size varied depending on the location of the fracture and bone size. Eight of nine fractures treated with 3.5-mm compression plates healed uneventfully. All 11 open fractures, eight from bullet wounds, healed uneventfully after early plating. Fifteen radial nerve injuries were associated with the fractures. Twelve anatomically intact radial nerve palsies recovered in 17 weeks on average after plate fixation. One lacerated nerve was sutured and recovered. One nerve with segmental loss associated with an open fracture was left unrepaired, as was an avulsed nerve associated with a closed fracture. The dissection required for plate fixation provides information that may be helpful in determining appropriate treatment of radial nerve injuries and the prognosis for spontaneous return of function.

Fracture treatment for the multiply injured patient.

Multiply injured patients are benefited by an intradisciplinary approach to treatment. Consultants provide expertise in the treatment of particular injured systems. Resuscitation and diagnostic evaluation are life-saving priorities of treatment in the emergency room. Definitive surgical treatment of body cavity injury is combined with careful monitoring while the patient is under anesthesia. The orthopaedic surgeon's responsibility then is to stabilize the fractures, thus minimizing the risk of infection, lung failure, and debilitation so that the patient may be gotten out of bed and rehabilitation started. Prolonged recumbency is probably the worst thing that can happen to a traumatized patient. The goal of fracture treatment is bone union without infection and with stable soft tissue coverage and normal motion of associated joints. It is important to realize that in these multiply injured people, fractures of the femoral or tibial shafts and unstable pelvic fractures threaten survival and should be surgically treated as soon as feasible. The operative treatment of fractures of the humerus, forearm, knee, and ankle can be addressed on an emergent basis. The condition of the skin around the ankle and knee influences the timing of surgery; a 24-hour delay may preclude surgery for weeks because of swelling and blisters. Orthopaedic surgeons now are beginning to understand the concepts of spine instability and have devices to stabilize the fractures. We think that unstable fractures should be given the same priority that fractures of major long bones receive. Free vascularized tissue provides excellent coverage when skin loss occurs over the distal two-thirds of tibial fractures.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of the multiply injured patient: plans for treatment and problems of major trauma.

Certain principles involved in the treatment of fractures have stood the test of time. The thrust of modern orthopaedics has been to decrease morbidity by combining these principles with developments in physiology, bioengineering, radiology, and antibiotics. The goal remains anatomic bone union without infection and normal joint and muscle function. The surgeon's mission is to achieve this goal. For the multiply injured patient, survival depends on the quality of care. Surgical orientation permits one to stabilize the fractures and restore the patient to activities of daily living. Multiple fractures set the stage for multiple organ failure, and, as we have discussed, stabilization reduces the incidence of these problems. Basically, open fractures must be stabilized with plaster, traction, or surgery. Multiple fractures need rigid stabilization, which can be achieved with various techniques without jeopardizing limb or life. A simple, comprehensive plan should be implemented when the patient arrives in the emergency room. Treatment requires an interdisciplinary approach, with the surgeon heading a team of physicians, nurses, and technicians capable of handling the complications of each organ system. Teamwork and dedication to excellence by all involved will decrease mortality and morbidity. Survival is to be anticipated. If we have restored the anatomy early, before any organ failure, we are then ready to begin rehabilitation and achieve a much finer and enduring end result for the injured patient.

Anatomical demonstration of the nerve-supply to the flexor tendon.

A dissection of four unembalmed human fingers demonstrated a branch from the digital nerve which enters the flexor tendon sheath at the same place as the transverse branch of the digital artery. We conclude that this branch supplies the nerve fibres found within the vinculum.

Interlocking intramedullary fixation of hand fractures.

Reduction and stabilization can be especially difficult in treating comminuted hand fractures with bone loss or nonunion. Two cases are presented to illustrate a method of intramedullary fixation using an AO mini fragment reconstruction plate, which allows interlocking fixation proximally and distally. Any defect can be filled with corticocancellous bone graft. When necessary, this graft can be fixed to the metal plate that acts as a strut. The fixation obtained is stable against rotational, angular, and compressive forces, making it a useful adjunct to the hand surgeon's armamentarium.

Chemonucleolysis vs laminectomy.

Three hundred and nine patients having herniated nucleus pulposus syndrome were treated by chemonucleolysis with chymopapain. We analyzed the results of that treatment in the first 100 patients who had been followed up for two years. No significant allergic reactions, deaths, spinal cord injury or paralysis occurred. One patient had pulmonary embolus and another had a disk space infection. Diskitis did not occur. Of the 100 patients receiving chymopapain, 71% of the results were rated good to excellent; of those in a comparably followed-up group of 100 patients who underwent surgery, 63% of the results were rated good to excellent. The end result was achieved more quickly after chemonucleolysis and with less physiologic stress on the patient. The beneficial result was considered to be long lasting, and in our opinion, the quality of the end result was superior after chemonucleolysis.

Tibial plateau fractures.

Certain factors in tibial plateau fractures that lead to increased disability may be avoided by following the objectives of articular surface restoration, good internal fixation, early knee motion, strengthening exercises, and soft-tissue repair. In some types of fractures, traumatic arthritis may be unavoidable.

Intracapsular hip fractures: case reports and discussion.

Two cases of intracapsular hip fracture illustrate some of the treatment options available for Garden Stage IV fractures. In Case 1, a prosthesis was chosen because of the patient's physiologic age and poor general health. In Case 2, a compression screw augmented with a single-pin fixation to prevent rotation was used. This patient, although only 3 years younger than the first patient, was in good health. Although there was some posterior comminution, an attempt at fixation, allowing time for bone healing, was appropriate. Arthroplasty may be needed in several years if bone healing fails.

Spinal cord tumor presenting as a herniated lumbar disc.

The lesion encountered in this case was that of an intradural-extramedullary tumor. Histologic section showed an organized hematoma, which is a very rare tumor. In a recent review of the literature, only 85 cases have been reported, most in relation to a bleeding intraspinal neoplasm. Our case is especially unusual because there was no clotting abnormality or repeated lumbar punctures or arteriovenous malformation. This case also points out the necessity of a complete physical examination. A CT scan was initially negative because the scan started just below the tumor, hence it was never visualized. Metrizamide myelogram followed by the enhanced CT scan provides a more complete diagnostic study. In this patient's case, the CT scan would have led to inappropriate therapy, whether lumbar laminectomy or chemonucleolysis.

The small pin circular fixator for proximal tibial fractures with soft tissue compromise.

We used a Monticelli-Spinelli small pin circular external fixator in five cases, in combination with closed reduction or limited open reduction internal fixation, to salvage a satisfactory result in juxtaarticular, intraarticular fractures of the proximal tibia, when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin circular fixator allows juxtaarticular placement of the small pins, enhancing stabilization of the comminuted fractures, allowing early range of motion of the joint and early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this method as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.

The small pin circular fixator for distal tibial pilon fractures with soft tissue compromise.

A Monticelli-Spinelli small pin circular external fixator was used in combination with closed reduction or a limited open reduction internal fixation in five cases in an attempt to salvage a satisfactory result in distal tibia pilon fractures when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin fixator enhances the ability to perform a closed reduction through a technique that uses distraction with pins in the tibia and calcaneus, combined with correction of angulation by tensioning wires with a stop nut. Small pin stabilization of these comminuted fractures allows early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this technique as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.

Distraction pinning for radial metaphysis fractures.

Comminuted fractures of the distal radial metaphysis are inherently unstable. Reduction can be obtained utilizing traction, and then the fracture stabilized by placing pins proximal and distal to the fracture and incorporating these pins in a short-arm cast. The results of 36 patients treated in this manner were analyzed. An excellent result was achieved in 78% of the cases.

High vacuum as a method of reducing porosity of polymethylmethacrylate.

In total hip arthroplasty, fracture and subsequent premature loosening are directly related to the strength of the cement mantle serving as an interface between bone and prosthesis. The cement has been shown to be weakened by its porosity, which enhances the formation of microfractures that contribute to crack propagation. By means of a vacuum mixing method for preparing the cement, nearly all the porosity can be removed and cement strength enhanced by about 17%.

Ganglions of the proximal interphalangeal joint.

Ganglions of the proximal interphalangeal joint are uncommon. Six patients (nine ganglions) were treated surgically. The lesions presented on the ulnar aspect of the extensor mechanism between the lateral band and the central slip and communicated with the joint by means of a stalk. Mild degenerative joint disease was noted in each case. Surgical excision provided relief of symptoms, and no patient has experienced any recurrence to date.

A case report of malignant mesenchymoma with discussion of musculoskeletal tumor staging: the Enneking system.

A 54-year-old black man presented with a soft-tissue sarcoma of the left anterior thigh. Surgical staging studies and initial biopsy results identified the lesion as a grade IIB pleomorphic liposarcoma. After radical hip disarticulation, follow up pathologic studies of the disarticulated limb showed the tumor to be confined to the anterior compartment of the left thigh without extracompartmental extension. The post-excisional surgical pathology report identified at least four different malignant mesenchymal elements: liposarcoma, myosarcoma, chondrosarcoma, and extraosseous osteogenic sarcoma. The sarcoma was therefore reclassified as a malignant mesenchymoma. The fact that the tumor was found to be intracompartmental at the time of surgery changed the staging of the tumor to stage IIA. A radical surgical margin, as recommended by Enneking, remained the treatment of choice. Three months postoperatively, the patient had chest pain and dyspnea. Chest films revealed multiple pulmonary nodules and the patient died of pneumonia 3 months later.