Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Anatomical Description and Quantification of Articular Surface Area Visualized in a Cadaveric Model.

PURPOSE: Distal radius (DR) fracture repair using the volar locked plating technique typically involves indirect fracture reduction, assessed using fluoroscopy, without direct visualization of the articular surface. This method of fracture repair may be guided by the rationale that volar radiocarpal ligament disruption may cause radiocarpal instability, although direct articular visualization may facilitate improved fracture reduction. This study investigated anatomical feasibility and articular surface visualization using volar ligament-sparing radiocarpal arthrotomy pertinent to DR fracture repair. METHODS: Ten fresh-frozen cadaveric specimens of the upper extremity underwent volar arthrotomy via the standard flexor carpi radialis approach with partial longitudinal sectioning of the long radiolunate and partial transverse sectioning of the short radiolunate ligaments to visualize the articular surface of the DR. Following arthrotomy, the visible surface of the DR was analyzed using digital photography. The wrist was disarticulated, and the fully exposed articular surface was photographed. The visible area of the articular surface was quantified using digital imaging software by calculating the ratio of the surface area visualized using the arthrotomy to the total articular surface area. RESULTS: The percentage of the articular surface area of the DR visualized using the volar arthrotomy was 76% ± 7.6% (range, 69%-90%), including both the scaphoid facet, lunate facet, and scapholunate ridge. CONCLUSIONS: Volar radiocarpal arthrotomy allows clinically relevant visualization of the articular surface of the DR, including the scaphoid and lunate facets. CLINICAL RELEVANCE: Radiocarpal arthrotomy may facilitate improved articular reduction during DR fracture repair via the volar approach.

Ligament-Sparing Volar Radiocarpal Arthrotomy During Distal Radius Fracture Repair: Biomechanical Implications on Wrist Stability in a Cadaveric Model.

PURPOSE: Distal radius (DR) fracture fixation with volar locked plating typically uses indirect fracture reduction without direct visualization of the articular surface in an attempt to preserve the volar radiocarpal ligaments and prevent iatrogenic radiocarpal instability. This study assessed the biomechanical stability after a volar radiocarpal arthrotomy for direct articular visualization for DR fracture repair compared to a standard trans-flexor carpi radialis approach without arthrotomy in a cadaver model. METHODS: Ten fresh-frozen upper extremity matched-pair cadaveric specimens were tested. For each pair, one limb underwent trans-FCR approach with a volar arthrotomy that partially sectioned the long and short radiolunate ligaments to visualize the DR articular surface (Group 1). The contralateral limb underwent standard trans-FCR approach without arthrotomy (Group 2). Following capsular repair (Group 1), all specimens (Groups 1 and 2) underwent biomechanical testing, including axial loading (22.2 N, 44.5 N, 89.0 N, 177.9 N), volar translational, and dorsal translation loading (22.2 N, 44.5 N, 89.0 N) to assess carpal stability using both fluoroscopy and motion capture. Ulnar carpal translation was assessed using the Gilula method, measuring radiographic lunate overhang from the ulnar edge of the lunate fossa relative to the full width of the lunate. Dorsal and volar translation were assessed by measuring lunate overhang with respect to the dorsal or volar radial cortex. To simulate fractures with dorsal radiocarpal ligament disruption, the dorsal capsule was sectioned, and the biomechanical comparisons were repeated. RESULTS: Ulnar translation of the lunate remained below 2 mm for both groups in all testing scenarios. No significant differences were identified in ulnar, volar, or dorsal translation with increasing loads between the groups. CONCLUSIONS: This volar ligament-sparing radiocarpal arthrotomy did not cause biomechanical radiocarpal instability. CLINICAL RELEVANCE: This arthrotomy may provide enhanced visualization of the DR articular surface during fracture fixation without causing iatrogenic wrist instability.

Histologic and Functional Outcomes of Conduit Wrapping for Peripheral Nerve Repair: Early Results in a Rat Model.

BACKGROUND: The concept of utilizing a nerve conduit for augmentation of a primary nerve repair has been advocated as a method to prevent neural scarring and decrease adhesions. Despite clinical use, little is known about the effects of a nerve conduit wrapped around a primary repair. To better understand this, we investigated the histologic and functional effects of use of a nerve conduit wrapped around a rat sciatic nerve repair without tension. METHODS: Twenty Lewis' rats were divided into two groups of 10 rats each. In each group, unilateral sciatic nerve transection and repair were performed, with the opposite limb utilized as a matched control. In the first group, direct repair alone was performed; in the second group, this repair was augmented with a porcine submucosa conduit wrapped around the repair site. Sciatic functional index (SFI) was measured at 6 weeks with walking track analysis in both groups. Nonsurvival surgeries were then performed in all animals to harvest both the experimental and control nerves to measure histomorphometric parameters of recovery. Histomorphometric parameters assessed included total number of neurons, nerve fiber density, nerve fiber width, G-ratio, and percentage of debris. Unpaired t-test was used to compare outcomes between the two groups. RESULTS: All nerves healed uneventfully but compared with direct repair; conduit usage was associated with greater histologic debris, decreased axonal density, worse G-ratio, and worse SFI. No significant differences were found in total axon count or gastrocnemius weight. CONCLUSION: In the absence of segmental defects, conduit wrapping primary nerve repairs seem to be associated with worse functional and mixed histologic outcomes at 6 weeks, possibly due to debris from conduit resorption. While clinical implications are unclear, more basic science and clinical studies should be performed prior to widespread adoption of this practice.

Hand transplantation in the United States: A review of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Database.

Hand transplantation is the most common application of vascularized composite allotransplantation (VCA). Since July 3, 2014, VCAs were added to the definition of organs covered by federal regulation (the Organ Procurement and Transplantation Network (OPTN) Final Rule) and legislation (the National Organ Transplant Act). As such, VCA is subject to requirements including data submission. We performed an analysis of recipients reported to the OPTN to have received hand transplantation between 1999 and 2018. Forty-three patients were identified as having been listed for upper extremity transplantation in the United States. Of these, 22 received transplantation prior to July 3, 2014 and 10 from then to December 31, 2018. Of patients transplanted after 2014, posttransplant functional scores included a decrease in Disabilities of the Arm, Shoulder and Hand questionnaire in 3 of 10 patients, Carroll test scores ranging from 9 to 60 of 99, and monofilament testing with protective sensation achieved in 4 of 6 patients. Complications included rejection in nine recipients with Banff scores from II-IV. One patient experienced graft failure 5 days after transplantation. Of the remaining patients, two were reported as receiving monotherapy and seven receiving dual or triple immunosuppression therapy. The inclusion of VCA in the OPTN Final Rule standardized parameters for safe implementation and data collection.

A Multicenter Matched Cohort Study of Processed Nerve Allograft and Conduit in Digital Nerve Reconstruction.

PURPOSE: Biomaterials used to restore digital nerve continuity after injury associated with a defect may influence ultimate outcomes. An evaluation of matched cohorts undergoing digital nerve gap reconstruction was conducted to compare processed nerve allograft (PNA) and conduits. Based on scientific evidence and historical controls, we hypothesized that outcomes of PNA would be better than for conduit reconstruction. METHODS: We identified matched cohorts based on patient characteristics, medical history, mechanism of injury, and time to repair for digital nerve injuries with gaps up to 25 mm. Data were stratified into 2 gap length groups: short gaps of 14 mm or less and long gaps of 15 to 25 mm. Meaningful sensory recovery was defined as a Medical Research Council scale of S3 or greater. Comparisons of meaningful recovery were made by repair method between and across the gap length groups. RESULTS: Eight institutions contributed matched data sets for 110 subjects with 162 injuries. Outcomes data were available in 113 PNA and 49 conduit repairs. Meaningful recovery was reported in 61% of the conduit group, compared with 88% in the PNA group. In the group with a 14-mm or less gap, conduit and PNA outcomes were 67% and 92% meaningful recovery, respectively. In the 15- to 25-mm gap length group, conduit and PNA outcomes were 45% and 85% meaningful recovery, respectively. There were no reported adverse events in either treatment group. CONCLUSIONS: Outcomes of digital nerve reconstruction in this study using PNA were consistent and significantly better than those of conduits across all groups. As gap lengths increased, the proportion of patients in the conduit group with meaningful recovery decreased. This study supports the use of PNA for nerve gap reconstruction in digital nerve reconstructions up to 25 mm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Peripheral nerve repair throughout the body with processed nerve allografts: Results from a large multicenter study.

BACKGROUND: Peripheral nerve damage resulting in pain, loss of sensation, or motor function may necessitate a reconstruction with a bridging material. The RANGER® Registry was designed to evaluate outcomes following nerve repair with processed nerve allograft (Avance® Nerve Graft; Axogen; Alachua, FL). Here we report on the results from the largest peripheral nerve registry to-date. METHODS: This multicenter IRB-approved registry study collected data from patients repaired with processed nerve allograft (PNA). Sites followed their own standard of care for patient treatment and follow-up. Data were assessed for meaningful recovery, defined as ≥S3/M3 to remain consistent with previously published results, and comparisons were made to reference literature. RESULTS: The study included 385 subjects and 624 nerve repairs. Overall, 82% meaningful recovery (MR) was achieved across sensory, mixed, and motor nerve repairs up to gaps of 70 mm. No related adverse events were reported. There were no significant differences in MR across the nerve type, age, time-to-repair, and smoking status subgroups in the upper extremity (p > .05). Significant differences were noted by the mechanism of injury subgroups between complex injures (74%) as compared to lacerations (85%) or neuroma resections (94%) (p = .03) and by gap length between the <15 mm and 50-70 mm gap subgroups, 91 and 69% MR, respectively (p = .01). Results were comparable to historical literature for nerve autograft and exceed that of conduit. CONCLUSIONS: These findings provide clinical evidence to support the continued use of PNA up to 70 mm in sensory, mixed and motor nerve repair throughout the body and across a broad patient population.

Use of Processed Nerve Allografts to Repair Nerve Injuries Greater Than 25 mm in the Hand.

Processed nerve allografts (PNAs) have been demonstrated to have improved clinical results compared with hollow conduits for reconstruction of digital nerve gaps less than 25 mm; however, the use of PNAs for longer gaps warrants further clinical investigation. Long nerve gaps have been traditionally hard to study because of low incidence. The advent of the RANGER registry, a large, institutional review board-approved, active database for PNA (Avance Nerve Graft; AxoGen, Inc, Alachua, FL) has allowed evaluation of lower incidence subsets. The RANGER database was queried for digital nerve repairs of 25 mm or greater. Demographics, injury, treatment, and functional outcomes were recorded on standardized forms. Patients younger than 18 and those lacking quantitative follow-up data were excluded. Recovery was graded according to the Medical Research Council Classification for sensory function, with meaningful recovery defined as S3 or greater level. Fifty digital nerve injuries in 28 subjects were included. There were 22 male and 6 female subjects, and the mean age was 45. Three patients gave a previous history of diabetes, and there were 6 active smokers. The most commonly reported mechanisms of injury were saw injuries (n = 13), crushing injuries (n = 9), resection of neuroma (n = 9), amputation/avulsions (n = 8), sharp lacerations (n = 7), and blast/gunshots (n = 4). The average gap length was 35 ± 8 mm (range, 25-50 mm). Recovery to the S3 or greater level was reported in 86% of repairs. Static 2-point discrimination (s2PD) and Semmes-Weinstein monofilament (SWF) were the most common completed assessments. Mean s2PD in 24 repairs reporting 2PD data was 9 ± 4 mm. For the 38 repairs with SWF data, protective sensation was reported in 33 repairs, deep pressure in 2, and no recovery in 3. These data compared favorably with historical data for nerve autograft repairs, with reported levels of meaningful recovery of 60% to 88%. There were no reported adverse effects. Processed nerve allograft can be used to reconstruct long gap nerve defects in the hand with consistently high rates of meaningful recovery. Results for PNA repairs of digital nerve injuries with gaps longer than 25 mm compare favorably with historical reports for nerve autograft repair but without donor site morbidity.

Diagnosis and Arthroscopic Management of Dorsal Wrist Capsular Impingement.

PURPOSE: Dorsal wrist capsular impingement (DWCI) is characterized by pain attributable to impingement of dorsal capsular tissue during wrist extension. The diagnostic criteria and management algorithm for this condition have not been well established. The aims of our study were (1) to retrospectively review the clinical presentation and arthroscopic findings of patients treated surgically for DWCI and (2) to evaluate the outcomes of arthroscopic debridement for this condition. METHODS: A total of 19 patients were treated with arthroscopic debridement for isolated DWCI from 2006 to 2015 by two surgeons (M.J.R. and D.S.R.) at a single institution. A chart review was performed to gather information on clinical presentation, radiological findings, operative details, and outcomes including numeric pain scale rating, range of motion, Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand score. Patients were contacted at the time of the study for final telephone follow-up. RESULTS: Symptoms were present for a median of 12.5 months (range, 3.5-124.4 mo) prior to surgical intervention, and all patients had pain localized to the dorsal and central wrist with passive terminal wrist extension (100%; 19 of 19). We obtained magnetic resonance imaging in 66% of patients (12 of 19). Diagnostic arthroscopy yielded evidence of infolded, redundant dorsal capsular tissue in all cases (19 of 19), and there was no evidence of concomitant wrist pathology. Compared with preoperative values, postoperative improvements were seen in average numeric pain scale rating (6.0-1.9), Quick Disabilities of the Arm, Shoulder, and Hand score (45.8-4.8), and Mayo wrist score (50.0-87.8). These improvements were sustained at 41.6 months after surgery (range, 11.9-73.8 months). One complication of superficial cellulitis occurred. CONCLUSIONS: Dorsal wrist capsular impingement is a clinical diagnosis; magnetic resonance imaging may be helpful in evaluating for other pathologies. Diagnostic arthroscopy yields evidence of redundant dorsal capsular tissue, and arthroscopic debridement of this tissue offers a safe and effective treatment to improve pain and functional scores. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Perioperative Glucocorticoid Administration Improves Elbow Motion in Terrible Triad Injuries.

PURPOSE: Among patients who undergo surgical treatment of terrible triad elbow injuries (TTEI), we hypothesized that those who received perioperative glucocorticoid (GC) therapy would have improved postoperative pain and range of motion (ROM) and a similar complication rate compared with patients who did not receive GC therapy. METHODS: We retrospectively identified 26 patients who underwent surgical treatment of TTEI from 2009 to 2015. Thirteen patients received a single intraoperative dose of 10 mg intravenous dexamethasone followed with a 6-day oral methylprednisolone taper course (GC group), and 13 did not (control group). After surgery, patients were placed in an orthosis at 90° flexion with the forearm in pronation for 2 weeks, after which ROM was initiated. Patients were seen in clinic at 2, 6, 12, and 24 weeks after surgery, at which time numeric pain scale scores and ROM data were collected and any complications were noted. RESULTS: Compared with the control group, the GC group had a greater flexion-extension arc of motion at 24 weeks (132.5° vs 105.5°); significant differences were not found at earlier time points. Supination measurements were significantly greater for the GC group at every time point with a difference at final follow-up of 23.2° (61.0° vs. 84.2°). There were 5 complications in the control group (35.8%), 3 of which required additional surgery, and 3 complications in the GC group (23.1%), 1 of which required another surgery. No postoperative infections were found in either group. CONCLUSIONS: Perioperative glucocorticoid administration is associated with improved ROM after surgical treatment of TTEI. Flexion-extension, pronosupination arc of motion, and overall supination were significantly improved. Postoperative pain scores and complication rates were similar between GC and control groups. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Major Peripheral Nerve Injuries After Elbow Arthroscopy.

PURPOSE: To survey the American Society for Surgery of the Hand membership to determine the nature and distribution of nerve injuries treated after elbow arthroscopy. METHODS: An online survey was sent to all members of the American Society for Surgery of the Hand under an institutional review board-approved protocol. Collected data included the number of nerve injuries observed over a 5-year period, the nature of treatment required for the injuries, and the outcomes observed after any intervention. Responses were anonymous, and results were securely compiled. RESULTS: We obtained 372 responses. A total of 222 nerve injuries were reported. The most injured nerves reported were ulnar, radial, and posterior interosseous (38%, 22%, and 19%, respectively). Nearly half of all patients with injuries required operative intervention, including nerve graft, tendon transfer, nerve repair, or nerve transfer. Of the patients who sustained major injuries, those requiring intervention, 77% had partial or no motor recovery. All minor injuries resolved completely. CONCLUSIONS: Our results suggest that major nerve injuries after elbow arthroscopy are not rare occurrences and the risk of these injuries is likely under-reported in the literature. Furthermore, patients should be counseled on this risk because most nerve injuries show only partial or no functional recovery. With the more widespread practice of elbow arthroscopy, understanding the nature and sequelae of significant complications is critically important in ensuring patient safety and improving outcomes.

Radial to Axillary Nerve Transfers: A Combined Case Series.

PURPOSE: Loss of active shoulder abduction after brachial plexus or isolated axillary nerve injury is associated with a severe functional deficit. The purpose of this 2-center study was to retrospectively evaluate restoration of shoulder abduction after transfer of a radial nerve branch to the axillary nerve for patients after brachial plexus or axillary nerve injury. METHODS: Patients who underwent transfer of a radial nerve branch to the anterior branch of the axillary nerve between 2004 and 2014 were reviewed. A total of 27 patients with an average follow-up of 22 months were included. Outcome measures included pre- and postoperative shoulder abduction and triceps strength and active and passive shoulder range of motion. RESULTS: Shoulder abduction strength increased after surgery in 89% of patients. Average preoperative shoulder abduction was 12° compared with 114° after surgery. Twenty-two of 27 patients (81.5%) achieved at least M3 strength, with 17 of 27 patients (62.9%) achieving M4 strength. No differences were observed when subgroup analysis was performed for isolated nerve transfer versus multiple nerve transfer, mechanism of injury, injury level, branch of radial nerve transferred, or time from injury to surgery. A negative correlation was found comparing increasing age and both shoulder abduction strength and active shoulder abduction. No patients lost triceps strength after surgery. There were 4 patients who achieved no significant gain in shoulder abduction or deltoid strength and were deemed failures. No postoperative complications occurred. CONCLUSIONS: Transfer of a branch of the radial nerve to the anterior branch of the axillary nerve was successful in improving shoulder abduction strength and active shoulder motion in the majority of the patients with brachial plexus or isolated axillary nerve injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Olecranon fractures with sagittal splits treated with dual fixation.

PURPOSE: To assess the results of olecranon fractures with an intra-articular sagittal plane fracture managed by orthogonal fixation constructs. METHODS: A retrospective chart review was performed and 14 proximal ulna fractures with intra-articular comminution resulting in separate medial and lateral fragments were identified. All fractures were classified according to the Schatzker, Mayo, and AO classification systems. Postoperative functional assessment, Disabilities of the Arm, Shoulder, and Hand (DASH) score, time to union, and complications were recorded. RESULTS: Eleven patients were treated with both dorsal and lateral plates. Three patients were managed with a single dorsal plate and cerclage wires. All fractures healed. Mean length of follow-up was 15 months (range, 4-72 mo). Mean range of motion at final follow-up was a flexion-extension arc of 24° to 129° with 89° and 79° of pronation and supination, respectively. The most common complication was symptomatic hardware, leading to removal of hardware in 5 of 14 (36%) patients. Average postoperative Disabilities of the Arm, Shoulder, and Hand score was 7. Two patients developed heterotopic ossification and 1 patient required a local pedicled flap for soft-tissue coverage. CONCLUSIONS: Identification of this subset of fractures is critical to successful management. A supplemental lateral plate or cerclage wires can successfully manage these difficult fractures and achieve good outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical Outcomes of the Flexor Carpi Ulnaris Turnover Flap for Posterior Elbow Soft Tissue Defects.

PURPOSE: To report the clinical outcomes from 2 academic centers of the flexor carpi ulnaris (FCU) flap for coverage of posterior elbow soft tissue defects. METHODS: We retrospectively reviewed 17 patients who underwent an FCU flap for posterior elbow wound reconstruction over an 8-year period at 2 academic centers. Outcome measures included visual analog score for pain; Disabilities of the Arm, Shoulder, and Hand score; Mayo Elbow Performance score; range of motion; wound healing; grip strength; and isokinetic dynamometry for wrist flexion. Wilcoxon signed-rank test was used to make side-to-side comparisons between the operative and nonsurgical extremities, and nonparametric statistical methods were used to analyze results. RESULTS: All wounds healed successfully without need for revision surgery. Average visual analog, Disabilities of the Arm, Shoulder, and Hand, and Mayo Elbow Performance scores in the operative elbow were 1.8, 34, and 86, respectively. Average elbow arc of motion was 11° to 140° with 70° forearm pronation and 73° forearm supination. Compared with the nonsurgical side, grip strength on the operated side was 97% and wrist flexion peak torque was 89%. The operative limb had an average wrist flexion fatigue of 7%, compared with 22% for the nonsurgical arm. CONCLUSIONS: Patients receiving an FCU flap had reliable healing, minimal pain, good functional outcomes, and no meaningful deficits in grip strength or wrist flexion strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A comparison of débridement with and without anconeus muscle flap for treatment of refractory lateral epicondylitis.

BACKGROUND: Lateral epicondylitis is a common condition encountered by orthopedic surgeons. Whereas the majority of patients improve with conservative management, a small percentage will require surgery. The purpose of this study was to compare the clinical outcomes of surgical débridement of the common extensor origin alone with débridement combined with rotation of an anconeus muscle flap in patients who failed to respond to conservative management of chronic lateral epicondylitis. METHODS: Fifty-seven patients who failed to respond to a minimum of 5 months of conservative treatment for lateral epicondylitis were retrospectively reviewed. Patients in group 1 were treated with open débridement of the common extensor origin. Patients in group 2 were treated with open débridement combined with rotation of an anconeus muscle flap. Outcome measures included elbow range of motion, grip strength, visual analog scale (VAS) for pain score, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Statistical analyses were performed by Student's t test with 95% confidence intervals. RESULTS: At final follow-up, average DASH scores were significantly lower in group 2. There were no significant differences between the groups with regard to elbow range of motion or grip strength. VAS pain scores were significantly reduced in both groups. Preoperative VAS pain scores were significantly greater in group 2; however, at final follow-up, there was no significant difference between groups. There were no apparent complications in either group. CONCLUSIONS: In addition to débridement of the common extensor origin, the rotation of an anconeus muscle flap may improve outcomes in cases of lateral epicondylitis that require operative intervention.

The influence of thumb metacarpophalangeal joint rotation on the evaluation of ulnar collateral ligament injuries: a biomechanical study in a cadaver model.

PURPOSE: To determine whether variation in thumb metacarpophalangeal (MCP) joint pronosupination influences perceived ulnar collateral ligament (UCL) stability during clinical stress testing. METHODS: Twelve fresh-frozen specimens underwent sequential evaluation for the following conditions: ligament intact (LI), proper UCL deficient (-pUCL), and proper and accessory UCL deficient (UCL). Valgus stress testing was completed in both 0° and 30° MCP joint flexion for thumb pronation, neutral, and supination. RESULTS: Compared with neutral MCP joint rotation, supination decreased and pronation increased stability such that established treatment guidelines could be incorrectly applied. During evaluation in supination and 0° flexion, 9/12 -pUCL had greater than 35° laxity and, similarly, the mean laxity of -pUCL was similar to the UCL group in neutral rotation and 0° flexion, incorrectly suggesting a complete ligament tear. In comparison, mean laxity of the *UCL in pronation and 0° flexion was not different than -pUCL in neutral rotation and 0° flexion, emphasizing the stabilizing effect of pronation. CONCLUSIONS: Thumb MCP joint pronosupination significantly influenced the evaluation of joint stability, where pronation improved valgus stability in contrast to supination that tended to increase joint instability, In pronation and 0° flexion, a complete UCL injury could be misdiagnosed as a partial injury. In supination and 30° flexion, an intact UCL could be misdiagnosed as a partial UCL injury. In supination and 0°, a partial UCL injury could be misdiagnosed as a complete UCL injury. CLINICAL RELEVANCE: Accurate evaluation of thumb UCL stability is critical for guiding treatment. Variations in thumb MCP joint rotation during stress testing may influence clinical interpretation and, therefore, we recommend standardization of testing with the thumb MCP joint in neutral rotation.

Salvage of distal radius nonunion with a dorsal spanning distraction plate.

Treatment of nonunion after previous instrumentation of distal radius fractures represents a reconstructive challenge. Resultant osteopenia provides a poor substrate for fixation, often necessitating wrist fusion for salvage. A spanning dorsal distraction plate (bridge plate) can be a useful adjunct to neutralize forces across the wrist, alone or in combination with nonspanning plates to achieve union, salvage wrist function, and avoid wrist arthrodesis in distal radius nonunion.

Scaphoid nonunions treated with 2 headless compression screws and bone grafting.

PURPOSE: To evaluate union and complication rates associated with the use of 2 headless compression screws and bone grafting for the treatment of scaphoid nonunions. METHODS: A total of 19 patients (18 male and 1 female) at an average age of 21 years were treated with open reduction and internal fixation with 2 cannulated, headless, compression screws for scaphoid nonunions. Bone grafting techniques included corticocancellous autograft from the iliac crest in 14 patients, capsular-based vascularized distal radius graft in 3, and medial femoral condyle free vascularized bone graft in 2. Patients were treated an average 19 months after the injury. Fracture nonunions were at the waist (n = 12), proximal third (n = 5), or distal third (n = 2) of the scaphoid. Dorsal (n = 7) and volar (n = 12) surgical approaches were used. RESULTS: All fractures had clinical and radiographic evidence of bone union at an average of 3.6 months. Postoperative computed tomography scans were available in 13 patients and showed union without evidence of screw penetration of the scaphoid cortex. No complications occurred in this series, and no revision procedures have been necessary. CONCLUSIONS: Our results indicate that the use of 2 headless compression screws for the treatment of scaphoid nonunions is safe and effective. A variety of bone grafting techniques can be used with this technique. The use of 2 compression screws may provide superior biomechanical stability and ultimately improve outcomes measured with future long-term comparative studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Anatomic findings and complications after surgical treatment of chronic, partial distal biceps tendon tears: a case cohort comparison study.

PURPOSE: To describe pertinent anatomic findings during repair of chronic, partial distal biceps tendon tears and to compare the complications of surgery with a similar cohort of acute, complete tears. METHODS: Group 1 included 14 patients (15 elbows) with partial tears managed operatively an average of 10 months from onset of injury or symptoms. Group 2 included a matched cohort of 16 patients (17 elbows) treated for complete, acute tears an average of 19 days from injury. A retrospective review of all 30 patients focused on demographic data, intraoperative findings, and postoperative complications. A single, anterior incision was used in all cases with multiple suture anchors or a bicortical toggling button for fixation of the repair. RESULTS: We evaluated 27 men and 3 women with an average age of 55 years (group 1) and 48 years (group 2). Intratendinous ganglion formation at the site of rupture of the degenerative tendon was observed in 5 cases of partial tears and none of the complete tears. Partial tears involved the lateral aspect or short head of the biceps tendon insertion in all cases. Postoperative complications included lateral antebrachial cutaneous nerve neuritis in 8 group 1 patients and 6 group 2 patients and transient posterior interosseus nerve palsy in 3 group 1 patients. CONCLUSIONS: Partial distal biceps tendon ruptures showed a consistent pattern of pathology involving disruption of the lateral side of the tendon insertion involving the small head of the biceps. Degenerative intratendinous ganglion formation was present in one third of cases. Repair of chronic, partial distal biceps tendon injuries may have a higher incidence of posterior interosseous and lateral antebrachial cutaneous nerve palsies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Complex Elbow Fracture-Dislocations: An Algorithmic Approach to Treatment.

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

Ultrasound diagnosis of bony nerve entrapment: case series and literature review.

INTRODUCTION: Nerve entrapment due to osseous callus formation is a rare complication after bone fracture. Electrodiagnostic studies and routine radiographic imaging often fail to demonstrate the pathology. The diagnosis is difficult and is often made incidentally upon surgical exploration. Nerve ultrasonography has not been used routinely to assess such lesions. METHODS: We report 5 cases of nerve entrapment in osseous callus after fractures that occurred in 2011 and 2012. The diagnosis was made by ultrasound (US). We then performed a review of the relevant literature. CONCLUSIONS: US is becoming an invaluable tool for diagnosing peripheral nerve entrapments. The current cases suggest that nerve US should be strongly considered as an adjunctive diagnostic tool for nerve palsies developing after trauma.