Simple medial elbow dislocations: a rare injury at risk for early instability.

PURPOSE: To report the presentation, treatment, and outcomes of a series of simple medial elbow dislocations and to identify features distinguishing this injury from the more common dislocation patterns. METHODS: From 2000 to 2011, 4 cases of simple medial elbow dislocations were treated at a single referral center. Retrospective review was conducted to evaluate presentation, treatment, and outcomes. RESULTS: The mean patient age was 56 years (range, 49-61 y). All dislocations were in the nondominant arm of women after a fall from standing height. Two elbows had immediate closed reduction, and 2 elbows could not be reduced acutely. All elbows presented within 2.5 weeks of injury with recurrent instability or dislocation. Two patients also had acute symptoms of ulnar neuropathy. All patients had surgical repair of the lateral collateral ligament complex and extensor tendon origin. Three patients had ulnar nerve decompressions. All elbows were stable to valgus, varus, and rotatory stress testing, with no subjective instability at a minimum follow-up of 8 months (range, 8-144 mo). Three patients reported no pain. Symptoms of ulnar neuropathy resolved in all patients. Mean elbow range of motion was from 13° to 135° of extension/flexion, with full pronation and supination. CONCLUSIONS: Simple medial elbow dislocations may be at risk for early instability and may represent a more noteworthy soft tissue injury than typical dislocation patterns. Surgical treatment of early instability in these injuries led to acceptable patient outcomes.

Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients.

PURPOSE: To evaluate internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients greater than 60 years of age at two level 1 trauma centers. We specifically desired to determine whether patients would have acceptable results from the clinical standpoint of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and the radiographic measurements of ulnar variance, radial inclination, and palmar tilt. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, DASH score, and radiographic parameters and would, thereby, provide the upper extremity surgeon with another option for the treatment of these fractures. METHODS: A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated with internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications, and DASH scores were also obtained. RESULTS: We treated 33 patients (mean age, 70 y) with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed, and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50°, respectively. Mean pronation and supination were 79° and 77°, respectively. At final follow-up, the mean DASH score was 32. CONCLUSIONS: In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reconstruction of soft-tissue injury associated with lower extremity fracture.

Soft-tissue loss associated with lower extremity fracture poses a substantial reconstructive challenge. Following stabilization of life-threatening conditions and bony disruptions, the reconstructive team must address the soft-tissue envelope of the limb. The wound is managed with débridement followed by coverage. Coverage options range from basic to complex and include delayed primary closure, healing by secondary intention, skin grafting, local flap coverage, and distant tissue transfer. The choice of soft-tissue coverage method is based on its ability to provide an environment conducive to fracture healing. Understanding the merits and disadvantages of each reconstructive option helps to avoid undertreatment or overtreatment.

Anterior interosseous nerve palsy after open capsular release for elbow stiffness: report of 2 cases.

Surgical release of elbow contracture has been associated with injury to structures traversing the elbow. Injury to ulnar and radial nerves has been reported, but this review describes 2 cases of anterior interosseous nerve palsy after open release of an established elbow contracture.

Soft tissue reconstruction of the hand.

There are a number of insults that can compromise the soft tissue envelope of the hand. Soft tissue reconstruction seeks to restore both the aesthetic appearance and the function of the hand. The purpose of this review is to describe recent advances in hand soft tissue reconstruction. Skin grafts and skin substitutes both are useful reconstructive options for certain defects. Digital coverage continues to be subject to refinements that lead to better reconstructions. Flaps based on donor sites from the dorsal metacarpal artery system are finding continually expanding uses in hand reconstruction. Traditional notions of forearm-based donor tissue are being challenged, leading to better hand reconstructions with less donor morbidity. Finally, improvements in free tissue transfer enable the expansion of reconstructive possibilities available for hand coverage.

Outcome after vascularized bone grafting of scaphoid nonunions with avascular necrosis.

PURPOSE: Vascularized bone grafting has been proposed as a treatment for scaphoid nonunions with avascular necrosis of the proximal pole. The purpose of this investigation is to report the results of vascularized bone graft and internal fixation for established scaphoid nonunions with proximal pole avascular necrosis as measured by validated outcome instruments. METHODS: From 1996 to 2004, 30 consecutive patients with established scaphoid nonunion, proximal pole avascular necrosis, and no prior surgery were treated with open reduction and internal fixation in addition to a vascularized bone graft based on 1,2 intercompartmental supraretinacular artery. A total of 19 patients had nonunions of the scaphoid waist and 11 had nonunions of the proximal pole of the scaphoid. Preoperative and postoperative evaluation included measurement of clinical (grip strength and range of motion), radiographic (scapholunate angle, scaphoid height-to-length ratio, and radioscaphoid arthritis), function (Disabilities of the Arm, Shoulder, and Hand questionnaire) and satisfaction parameters. We recorded union and return to activity and analyzed data both in the aggregate and stratified by nonunion location. RESULTS: Union rate was 28 of 30 (93%) and time to union was 5.1 months (+/-2.4). Significant improvements were found for grip strength, Disabilities of the Arm, Shoulder, and Hand score, satisfaction score, and scaphoid height-to-length ratio (p < .01). No significant difference was found for composite wrist range of motion. Two patients experienced complications and required a second procedure to achieve union. A total of 28 of 30 (93%) of patients returned to work or sports activity at their preinjury level. CONCLUSIONS: The results of this investigation support the use of a vascularized bone graft for the treatment of scaphoid nonunions with avascular necrosis of the proximal pole.

Contact pressure at osteochondral donor sites in the patellofemoral joint.

BACKGROUND: The lowest contact pressure point is presumed to be the best site to harvest an osteochondral plug and minimize morbidity. HYPOTHESIS: Patellofemoral contact pressures are not uniform and are lowest along the medial patellofemoral articulation. STUDY DESIGN: Controlled laboratory study. METHODS: Seven cadaveric knees were tested with an electroresistive, dynamic pressure sensor placed onto the femoral side of the patellofemoral joint. The extensor mechanism was loaded with 89.1 N and 178.2 N, and the knee was manually cycled 3 times (0 degrees -105 degrees ) per load. Mean trochlear pressures were calculated. RESULTS: Mean contact pressures were greatest in the central trochlea (5.80 kgf/cm(2)), followed by the lateral (2.56 kgf/cm(2)) and medial trochlea (1.60 kgf/cm(2)) at 89.1 N (P <.05). At 178.2 N, pressures increased to 9.47, 5.81, and 2.75 kgf/cm(2), respectively (P <.05). Lateral trochlear pressures decreased moving distally from 1.25 to 0.50 kgf/cm(2) at 89.1 N and 4.57 to 1.29 kgf/cm(2) at 178.2 N. CONCLUSIONS: Contact pressures are lowest along the medial trochlea and decrease distally along the lateral trochlea. CLINICAL RELEVANCE: Osteochondral plugs from the medial femoral trochlea may be desirable if trochlear size permits. If harvesting from the lateral femoral trochlea, consider harvesting distally near the sulcus terminalis.

One-stage Integra coverage for fingertip injuries.

BACKGROUND: We hypothesize that one-stage Integra skin coverage is an effective treatment modality for the treatment of fingertip defects. METHODS: Nine patients who sustained fingertip injuries were treated with one-stage Integra coverage. In all cases, Integra was placed directly on bone. Static two-point discrimination and the Semmes-Weinstein Monofilament Test (SWMFT) were used to determine the sensations of the affected and opposite unaffected digit. The QuickDASH, Cold Intolerance Symptom Severity (CISS), visual analog scale (VAS), and a 0-10-point pain scale were administered to assess patient function, satisfaction, and pain levels. RESULTS: The mean age was 53.1 years (39-61). There were 8 males and 1 female. The average area covered was 2.3 cm(2) (1.0-3.2). The mean follow-up duration was 16 months (8-46). The median QuickDASH, CISS score, VAS patient satisfaction, and 0-10 pain score were 9.1 (2.3-40.9), 18 (4-30), 10 (most satisfied) (7-10), and 0 (0-3), respectively. Five patients were evaluated for their digital sensory perception. The mean static two-point discrimination was 9.6 mm for the affected digit and 4.6 mm for the opposite unaffected digit. The median SWMFT was 4.31 for the affected digit and 3.61 for the opposite unaffected digit. CONCLUSION: For small soft tissue and bone defects involving the fingertip, the use of Integra without further skin grafting appears to be effective, avoids the morbidity of the donor site, and avoids a second surgery. Despite mild sensory deficits, patients were satisfied with the results and fully functional during short-term follow-up.

Osteocapsular debridement for elbow arthritis.

Open capsular debridement is an excellent option for the treatment of elbow arthritis. This technique is particularly indicated in a patient population physiologically younger than 60 years. Given the young age and high functional demand of patients with primary osteoarthritis of the elbow, prosthetic replacement is generally not recommended. Open capsular debridement preserves the native joint and thus does not inherently require permanent activity modification as does replacement arthroplasty.

Glatiramer acetate immune system augmentation for peripheral nerve regeneration in rat crushed sciatic nerve model.

BACKGROUND: Protective antiself response to nervous system injury has been reported to be mediated by a T-cell subpopulation that can recognize self-antigens. Immune cells have been shown to play a role in the regulation of motor neuron survival after a peripheral nerve injury. The objective of the present study was to evaluate the effects of immune system augmentation with use of the antigen glatiramer acetate, which is known to affect T-cell immunity, on peripheral nerve regeneration. METHODS: Wild-type and nude-type (T-cell-deficient) rats underwent crush injury of the sciatic nerve. Three and six weeks after the injury, the sciatic nerve was examined, both functionally (on the basis of footprint analysis and the tibialis anterior muscle response and weight) and histologically (on the basis of axon count). RESULTS: Significantly greater muscle responses were measured after three weeks in the group of wild-type rats that were treated with glatiramer acetate (control limb:injured limb ratio, 0.05 for the glatiramer acetate group [n = 9], compared with 0.51 for the saline solution group [n = 8]; p < 0.05). Higher axon counts were also found in this group (control limb:injured limb ratio, -0.07 for the glatiramer acetate group [n = 10], compared with 0.29 for the saline solution group [n = 8]; p < 0.05). The nude-type rats showed no response to the intervention after three weeks but showed a delayed response after six weeks. A second dose of glatiramer acetate, delivered forty-eight hours after the injury, did not result in an improved response as compared with the control groups. CONCLUSIONS: We found that a single treatment with glatiramer acetate resulted in accelerated functional and histological recovery after sciatic nerve crush injury. The role of T-cell immunity in the mechanism of glatiramer acetate was suggested by the partial and late response found in the T-cell-deficient rats.

Osteoid osteoma of the scaphoid presenting with radiocarpal arthritis: a case report.

A case of osteoid osteoma of the scaphoid presenting as painful monoarticular arthritis is presented. Degenerative arthritis, associated with osteoid osteoma of the carpus, has not been described. The implications for treatment are discussed.

Arthroscopic resection of pisotriquetral joint loose body: a case report.

Pisotriquetral disease is a key element in the differential diagnosis of ulnar-sided wrist pain. A loose body within the pisotriquetral joint is an uncommon entity. After appropriate diagnosis, arthroscopic removal is a feasible alternative to open resection.

Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint: a retrospective comparison of pull-out sutures and bone anchor techniques.

BACKGROUND: The use of intraosseous suture anchors in the treatment of ruptures of the ulnar collateral ligament of the thumb metacarpophalangeal joint has previously been described. However, no direct comparisons exist of ulnar collateral ligament repair with bone anchor versus repair with a pull-out button and immobilization. METHODS: Two cohorts of patients with complete rupture of the ulnar collateral ligament of the thumb metacarpophalangeal joint were compared. Thirty patients in each cohort underwent repair of the ulnar collateral ligament with either an intraosseous suture anchor followed by early mobilization or a pull-out suture tied over a button with cast immobilization. Average follow-up was 29 months. RESULTS: At follow-up, range of motion at the metacarpophalangeal and interphalangeal joints for the anchor group averaged 97 percent of that of the contralateral side compared with 86 percent and 87 percent, respectively, for the button group. For the anchor group, pinch strength averaged 101 percent that of the contralateral side compared with 95 percent for the button group. No significant difference was noted between the groups for grip strength. Average tourniquet time for the anchor group was 28 minutes compared with 43 minutes for the button group. Soft-tissue complications were present in 27 percent of patients (eight of 30) in the pull-out button group compared with 7 percent (two of 30) in the anchor group. Cost analysis demonstrates an approximately $140-per-patient savings when using the suture anchor. CONCLUSIONS: Both repair methods are safe and effective for treating thumb ulnar collateral ligament injuries. Suture anchors allow for an accelerated rehabilitation protocol, which may account for the improved range of motion and pinch strength at follow-up.

Biomechanical evaluation of 10 configurations of a small external fixator set.

The small AO (Synthes, Paoli, Pa) external fixator is a valuable tool for the treatment of distal radius fractures. The construct has many possible bar and pin configurations. However, there are no data regarding which construct is optimal with respect to strength and versatility. We tested 10 configurations to determine bending stiffness, rotation, and axial loading. Although slight variations were found between constructs for bending and rotation forces, there were marked differences between constructs during axial loading. A frame design without bar-to-bar clamps was determined stiffest. However, this configuration may be more difficult to apply and adjust in the clinical setting. Although an "ideal" construct applicable to all fracture types does not exist, knowledge of the strengths of various configurations may allow for optimization of fixator assembly to meet specific clinical needs.

The use of tensor fascia lata interposition grafts for the treatment of posttraumatic radioulnar synostosis.

PURPOSE: There is no agreement on the ideal treatment of traumatic radioulnar synostosis, especially the type of interposition material to be used. The purpose of this study is to report our experience with synostosis resection and interposition of tensor fascia lata grafts. METHODS: A chart review was conducted for all patients treated for posttraumatic radioulnar synostosis between 2000 and 2004. Demographic data, mechanism of injury, length of time to synostosis resection, range-of-motion, patient satisfaction, and postoperative complications were analyzed. RESULTS: Thirteen patients were identified for this study. The mean preoperative pronation was 14 degrees and the mean postoperative pronation was 62 degrees. The mean preoperative supination was 4 degrees and the mean postoperative supination was 62 degrees. The mean follow-up time was 30 months. CONCLUSIONS: These results indicate that synostosis resection with tensor fascia lata graft interposition is an effective technique for the treatment of posttraumatic radioulnar synostosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Comparison of pullout button versus suture anchor for zone I flexor tendon repair.

PURPOSE: To evaluate the clinical outcome after repair of zone I flexor tendon injuries using either the pullout button technique or suture anchors placed in the distal phalanx. METHODS: Between 1998 and 2002 we treated 26 consecutive zone I flexor tendon injuries. Thirteen patients had repairs from 1998 to 2000 using a modified pullout button technique (group A) and 13 patients had repair using suture anchors placed in the distal phalanx (group B). Patient characteristics were similar for both groups. The same postoperative flexor tendon rehabilitation protocol and follow-up schedule were used for both groups. Evaluation included range of motion, sensibility and grip strength, failure, complications, and return to work. The Student t test was used to determine significant differences. RESULTS: All patients completed 1 year of follow-up evaluation. There were 2 infections in group A that resolved with oral antibiotics and no infections in group B. There were no tendon repair failures and no repeat surgeries in either group. At final follow-up evaluation there were no statistically significant differences for the following end points: sensibility (Semmes-Weinstein monofilament testing and 2-point discrimination), active range of motion (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined motion), flexion contracture (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined contracture), and grip strength (injured tendon as a percent of the contralateral uninjured tendon). The suture anchor group had a statistically significant improvement for time to return to work. CONCLUSIONS: There was no significant difference in the clinical outcome after flexor tendon repair using either suture anchors or the pullout button technique. A significant improvement was found for time to return to work for repairs using the suture anchor technique. Flexor tendon repair can be achieved using suture anchors placed in the distal phalanx, thereby avoiding the potential morbidity associated with the pullout button technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.

Normalization of the Constant score.

The strength of the normal shoulder may differ by gender and deteriorate with age. Thus, the Constant score may also decrease in absolute value while still reflecting a normal score. To account for age- and gender-related differences, normal results for this scale must be determined across a population of patients without shoulder disease. Patients presenting for evaluation of nonshoulder conditions participated. A subjective questionnaire was completed. Range of motion and strength were measured. This analysis includes the data of 441 patients. The mean Constant score for men was significantly greater than that for women in each age group ( P < .05). Significant age-related differences were noted in each group ( P < .05). Normative values for the Constant score based on age and gender were determined. The adjusted score represents the gender- and age-matched function of the shoulder and is useful in the evaluation of shoulder outcomes.