Posterior bone-grafting for infected ununited fracture of the tibia.

Twenty-three patients with severe open tibial fractures complicated by established deep infection and delay or failure of union were treated with posterior tibial bone-grafting. This was followed by immediate ambulation in a plaster cast. Tibial union was achieved in all twenty-three patients. Drainage ceased prior to or simultaneously with union in twenty-one patients, including twelve of fourteen patients who had indolent drainage from the anterior compartment of the leg at the time of posterior tibial bone-grafting.

Greater trochanteric hip arthroplasty in children with loss of the femoral head.

In seventeen children with catastrophic loss of the femoral head, the hip was salvaged by greater trochanteric arthroplasty. The average follow-up of these patients was eleven years, and fourteen patients were followed to skeletal maturity or longer. In Group I, consisting of four patients with greater trochanteric arthroplasty alone, good initial stability gradually deteriorated as subluxation occurred, accompanied by a proportionate return of abductor limp, loss of hip motion, and an increased rate of degenerative changes in the joint. Group II, consisting of eight patients who had either acetabuloplasty or innominate osteotomy in addition to greater trochanteric arthroplasty, had only slightly improved hip containment and results similar to those in Group I. Spontaneous ankylosis of the hip occurred in six of the patients in those two groups. The best results were obtained in five patients in Groups III and IV who had the procedure supplemented by proximal femoral varus osteotomy.

Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius.

Sixty patients who had a displaced intra-articular fracture of the distal end of the radius were managed with manipulative reduction and internal fixation performed under both fluoroscopic and arthroscopic guidance. According to the AO/ASIF classification system, seven fractures were type B1, two were type B2, three were type B3, thirteen were type C1, twelve were type C2, and twenty-three were type C3. Forty-one patients (68 per cent) had soft-tissue injuries of the wrist, including tears of the triangular fibrocartilage complex (twenty-six patients), the scapholunate interosseous ligament (nineteen), and the lunotriquetral interosseous ligament (nine). Thirteen patients had two soft-tissue injuries. Intracarpal soft-tissue injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface or the radius.

Correction of abduction. Deformity of the small finger caused by avulsion of the insertion of the third volar interosseous muscle.

Wartenberg described the clinical sign of the abducted extended small finger that can result from ulnar nerve palsy. When this sign occurs in ulnar nerve palsy, it is a result of imbalance created by paralysis of the third volar interosseous muscle allowing the extensor digiti minimi to abduct the small finger as the finger is extended. If the third volar interosseous muscle is traumatically avulsed at its insertion and the ulnar nerve is intact, the abductor digiti minimi manus is an additional deforming force.

Rigid internal fixation in the hand: 104 cases.

One-hundred and four patients with fractures of the metacarpals and phalanges have been treated with rigid internal fixation over a 6-year period. Patients with both open and closed injuries had their fractures fixed by tension band wires, interosseous compression screws (lag screws), or plates and screws. The concepts of primary bone healing and its variations, methods of fixation, and the importance of interfragmentary compression are defined and stressed. Illustrative cases of each technique are described and the applicable principles are enunciated.

Immediate internal fixation of open fractures of the diaphysis of the forearm.

Immediate (within 24 h) open reduction and internal fixation of 103 open fractures of one or both bones of the forearm was accomplished in 69 patients between 1980 and 1989. Fifty-four of the 103 patients were reevaluated 1 to 7 years postinjury (average 2.5 years) to determine the efficacy of this treatment. Forty-five (90%) of the 50 patients with Grade I, II, or IIIA injuries had satisfactory results. The four patients with Grade IIIB or IIIC injuries had unacceptable results. This study demonstrates, as have previous investigations, that immediate open reduction and internal fixation of open forearm fractures provide acceptable results in Grades I, II, and selected Grade III injuries. The subdivision of Grade III fractures into A, B, and C types provides a previously unreported statistically significant difference in the results obtained in management of these injuries. The difference in results in Grade I, II, and IIIA injuries as compared to the Grade IIIB and C injuries was statistically significant (p = 0.0004). The difference in Grade IIIA injuries as compared to Grade IIIB and C injuries was also significant (p = 0.014). Immediate open reduction and internal fixation can be recommended in Grade I, II, and IIIA open forearm fractures. Although it is unclear from this report whether the results in Grade IIIB and C fractures were due to the management protocol, the severity of the initial injury, or combined factors, immediate open reduction and plate fixation yielded poor results in these injuries.

Buttress pinning in the unstable distal radial fracture. A modification of the Kapandji technique.

Between 1989 and 1993, 20 patients with distal radial fractures were treated with a buttressing technique felt to be safe, effective and simple. Out of the initial 20 patients, 16 have been followed-up and are reported. The technique uses an intramedullary styloid pin and a combined extramedullary-intramedullary dorsal buttress pin. The insertion technique and the use of a medial corner pin are illustrated. Results are evaluated from both final X-ray appearance as well as return of function using the five X-ray parameters of Abbasazadegan et al (1989) and the Mayo modification of the Green and O'Brien wrist score (Cooney et al, 1987). The average score on return of function was 78 (two excellent, eight good, six fair). Final axial shortening averaged -1.4 mm (+5 mm--4 mm), radial displacement averaged 0.68 mm (0 mm-5 mm), radial angle averaged 24.75 degrees (18 degrees-34 degrees), dorsal angle averaged +8.25 degrees (-5 degrees-25 degrees) and dorsal displacement averaged +1.31 (0 mm(-)+12 mm). From this study we recognize the need for a posterior medial pin, and that routine stress views after pinning can yield information concerning carpal instability, palmar instability and the need for bone grafting.

Open reduction and internal fixation method for fractures at the proximal interphalangeal joint.

When fragment size and mineralization permit, unstable and displaced proximal interphalangeal joint fractures can be secured in an anatomic position by any one of a number of direct (through the fragments) or indirect (buttress) pinning or screw fixation techniques. Transcutaneous or limited open reduction and fixation techniques are preferred in an effort to minimize additional soft tissue trauma and scarring. Plating is reserved for fractures otherwise difficult, if not impossible, to retain. The objectives of these internal fixation techniques are pain control and early active functional restoration.

Stabilization of fractures in the hand and wrist with traumatic soft tissue and bone loss.

Open type III fractures of the hand or wrist with severe bone and soft tissue loss justify aggressive treatment to restore anatomy, assure healing, and maximize functional recovery. The techniques of modern wound excision used at initial surgery predictably result in a decompressed and surgically clean wound within a few days from injury in the vast majority of cases. This allows a safe application of delayed primary internal fixation and bone grafting for fracture restoration or joint arthrodesis as well as early wound closure or coverage. The immediate or early application of stable external devices, internal fixation, or combinations of the two along with early bone grafting restores the structural integrity of the skeleton, reduces pain, protects other repaired and reconstructed tissues, promotes the healing, and supports early and intensive functional rehabilitation of the hand and wrist. Early wound closure or coverage minimizes scar formation. Together, the early sequencing of effective wound debridement with skeletal stabilization and bone grafting and early wound closure or coverage provide the most favorable circumstances for healing and functional recovery of the seriously damaged hand and wrist.

Arthroscopic management of intra-articular distal radius fractures.

Wrist arthroscopy is increasingly becoming recognized as an important adjunct in the management of displaced intra-articular fractures of the distal radius. Anatomic restoration of the articular surface is possible under bright, magnified conditions. Osteochondral loose bodies and associated intracarpal soft tissue injuries that may not be apparent on plain radiographs are detected and simultaneously managed. A method of management for displaced distal radius fractures using wrist arthroscopy and a combination of percutaneous and limited open reduction techniques are described.

Osteomyelitis of the hand.

Osteomyelitis involving the tubular bones of the hand is a rare and potentially devastating disease. An early and accurate diagnosis combined with aggressive surgical debridement and appropriate antibiotics remains the cornerstone of treatment. This article reviews current principles involving the etiology, pathophysiology, diagnosis, and treatment of osteomyelitis of the hand.

Septic arthritis and osteomyelitis.

The pathophysiology, bacteriology, diagnosis, and treatment of septic arthritis and osteomyelitis are presented. Possible complications are reviewed and illustrated.

Traumatic combined radial and ulnar axial wrist dislocation.

In axial wrist dislocation, the proximal and distal transverse arches are disrupted and the carpus and metacarpal bases are split longitudinally. Early reduction and stabilization of the dislocation combined with exploration and decompression provide the best results.

Anterior shoulder dislocation with posterior displacement of the long head of the biceps tendon. Arthrographic findings. A case report.

An acute anterior dislocation of the shoulder was accompanied by disruption and posterior displacement of the long head of the biceps tendon. This prevented concentric reduction of the humeral head into the glenoid and restricted shoulder motion. The diagnosis was confirmed by arthrogram.

Mechanical properties of 3M staples in bone block models.

The use of power driven staples is an accepted method of fixation for small bones of the hand and wrist and of the foot and ankle. The staples must be applied to flat or nearly flat surfaces. A synthetic model was developed to evaluate the ability of the 3M power driven staple system to resist failure due to pulling out of the staples in cantilever bending, tension, and torsion. Three different staple configurations and two leg lengths were evaluated in each of the test modes. Results indicated statistically significant differences between one and two staple configurations and between longer and shorter leg lengths. There was clear superiority of the two staple configurations and of longer leg lengths.

Tire explosion injuries.

Twenty-five patients hospitalized with injuries sustained from tire explosions from 1980 to 1987 were reviewed. Injuries occurred directly from the tire rim or parts of its assembly, from the patient being thrown against adjacent unyielding structures, or a combination of these. Lethal or life-threatening injuries do occur, so these patients initially must be triaged as polytrauma patients. Resuscitation and expeditious attention to life-threatening injuries must be provided when necessary. Serious head, facial, eye, and upper extremity injuries occurred frequently. Pelvic and long-bone fractures, particularly those of the femur, are stabilized primarily as part of the overall treatment of the polytraumatized patient. Open fractures and fractures with arterial injuries and/or compartment syndromes are primarily decompressed, debrided, and appropriately stabilized. After life-threatening and limb-threatening injuries are attended, eye injuries that threaten sight should be addressed. While hand, wrist, and other upper extremity injuries that do not fall in the above categories may not require immediate or primary treatment, they are often critical in determining the patient's final outcome. This is particularly true since most patients are manual workers, often mechanics. Therefore, hand, wrist, and upper extremity injuries should be treated as early as possible and in parallel with other injuries to achieve optimal results and minimize impairment, disability, and time and economic loss from work. Strong emphasis should be placed on education and safety training in preventing this severe form of civilian trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

The arthroscopic management of intra-articular distal radius fractures.

Intra-operative arthroscopy and fluoroscopy provide improved visualisation and guide the restoration of intra-articular distal radial fractures while minimising the operative dissection required for their stabilisation. Radial styloid fractures, distal radial fractures with dorsal, palmar or combined ulnar-sided "die punch" fragments, palmar and dorsal Barton's fractures, and various three- and four-part intra-articular fractures without significant bone loss or defect are especially suited for this technique. The experienced arthroscopist may wish to apply the technique to more severely comminuted intra-articular fractures. Bone defects may be approached through a limited dorsal incision traversing the 3rd dorsal wrist compartment. Arthroscopy and fluoroscopy may be used adjunctively to assess fracture reduction and fixation. Arthoscopy further facilitates initial treatment by allowing direct joint visualisation, debridement, the removal of small free intra-articular fragments, and the recognition and early treatment of wrist ligament injuries, particularly those not appreciated by X-ray evaluation

Early wrist arthrodesis for irreparable intra-articular distal radial fractures.

When articular restoration and congruity cannot be accomplished in distal radial fractures owing to severe articular bone loss or comminution, early wrist arthrodesis should be considered. This procedure rapidly restores wrist alignment and stability and controls pain. Arthrodesis is a highly reliable and definitive procedure that optimises the opportunity for early functional and occupational recovery while minimising the risks of developing stiff digits or chronic pain in injuries otherwise doomed from the start of treatment to result in severe wrist stiffness and post-traumatic arthritis. Simultaneous proximal row carpectomy or the use of ipsilateral local bone graft donor sites, such as the distal radius or proximal ulna, decrease both initial treatment and hospital costs and morbidity. Wrist arthrodesis is also effective when polytrauma or multiple fractures co-exist. Successful early treatment may expedite return to work and reduce lost time and wages resulting from the injury.