Ulnar Shortening Osteotomy: Are Complications Under Reported?

Ulnar shortening osteotomy is an accepted treatment for ulnar impaction syndrome and numerous techniques for have been described in the literature. We present our single surgeon case series over 10 years of oblique ulnar shortening osteotomy using a jig technique. A review of the current literature with reference to the risk of complications is included. All patients undergoing ulnar shortening osteotomy from 2001 to 2011 were identified and case-notes were reviewed retrospectively. Risks of complications included metalwork irritation (51 %), non-union (6.3 %), refracture (1.6 %) and chronic regional pain syndrome (1.6 %). Oblique ulnar osteotomy using a jig technique is reliable and reproducible in shortening the ulna and maintaining alignment, rotation and compression at the osteotomy site. Symptoms improved in the majority of patients. However, the morbidity associated with the procedure may be underestimated as highlighted by our complication rates. Surgeons should counsel patients appropriately when offering ulnar shortening osteotomy.

Bioabsorbable fixation of scaphoid fractures and non-unions; analysis of early clinical outcomes.

The vast majority of devices used for internal fixation of the scaphoid are metallic. This two-center study aimed to report the results of scaphoid fixation using a cannulated, bioabsorbable device made from a hydroxyapatite and poly-L-lactide composite in 29 consecutive patients. Fixation was performed for seven acute fractures and twenty-two established non-unions. Union was achieved in 72.4% of patients. Six of the acute fractures and fifteen of the non-unions united successfully. Modified Mayo Wrist Score ranged between good to excellent in all patients who successfully united, whereas patients who failed to unite ranged between poor to excellent, with one poor and two moderate scores. No adverse biocompatibility reactions were seen. Two failures with broken screws were re-explored and one of these was thought to be due to screw mal-placement. The device used is an alternative to conventional metal implants and produces comparable union rates to metallic devices in the short term.

"Mood rings": a new method of objective clinical assessment of peripheral nerve injuries.

The clinical assessment of patients with peripheral nerve injury is primarily dependent on subjective clinical examination. We aimed to assess whether a thermotropic liquid crystal ring (TLC-ring) could provide the basis for an objective assessment of peripheral nerve injury by detecting temperature changes in the digits innervated by the damaged nerve. A group of patients with known median, ulnar or both digital nerve injuries were compared against a control group. TLC-rings, marketed to the general public as "mood rings", were applied to the affected and unaffected digits and the colour change recorded. Areas with nerve damage showed a statistically significant difference in colour response to those without damage. This study establishes the ability of TLCs to detect cutaneous temperature changes associated with peripheral nerve injuries. Further studies and improvements are needed to refine TLC as an acute assessment tool for peripheral nerve injuries.

Thermometric diagnosis of peripheral nerve injuries. Assessment of the diagnostic accuracy of a new practical technique.

The diagnosis of nerve injury using thermotropic liquid crystal temperature strips was compared blindly and prospectively against operative findings in 36 patients requiring surgical exploration for unilateral upper limb lacerations with suspected nerve injury. Thermotropic liquid crystal strips were applied to affected and non-affected segments in both hands in all subjects. A pilot study showed that a simple unilateral laceration without nerve injury results in a cutaneous temperature difference between limbs, but not within each limb. Thus, for detection of a nerve injury, comparison was made against the unaffected nerve distribution in the same hand. Receiver operating characteristic curve analysis showed that an absolute temperature difference > or = 1.0 degrees C was diagnostic of a nerve injury (area under the curve = 0.985, sensitivity = 100%, specificity = 93.8%). Thermotropic liquid crystal strip assessment is a new, reliable and objective method for the diagnosis of traumatic peripheral nerve injuries. If implemented in the acute setting, it could improve the reliability of clinical assessment and reduce the number of negative surgical explorations.

Rotational alignment of the finger nails in a normal population.

We measured the alignment of the nails in the hands of 100 normal adults with the interphalangeal joints extended and the metacarpophalangeal (MCP) joints at 0 degrees and 90 degrees. All fingers were naturally supinated (i.e. rotated towards the thumb), the index and little being the most supinated. When examining individual hands in MCP joint extension, only 17% of hands had all nails parallel. With the MCP joints flexed, this improved to 56%. If the little finger was excluded, this improved to 78%. When comparing matching fingers from the two hands, 76% of little, 83% of ring, 77% of middle and 80% of index fingers matched. Thumbnails were assessed in extension and found to match the other side in 95% of individuals. This study identifies that examination of the injured hand alone with all joints extended is an unreliable method of assessing malrotation following fracture, especially in the little finger. Comparing matching fingers in the two hands is more reliable, but there is still substantial variation in approximately 20% of normal individuals.

Fifth metacarpal neck fractures: is follow-up required?

This study examines the premise that follow-up after fifth metacarpal neck fractures is unnecessary after initial assessment in a hand clinic. Forty consecutive patients with this fracture were managed in plaster and followed up. The next 38 patients were treated with neighbour strapping, given information sheets and no follow-up visits were arranged. In the first group, most return visits were for removal of plaster. Almost half of the appointments, thereafter, were not attended. In the second group, only two patients returned to the clinic, one with minor complaints and one with a repeat injury. Patients reported better satisfaction when managed with neighbour strapping (P=0.04) and without regular follow-up visits (P<0.01). The time to return to work was a mean of 5 weeks and 2.7 weeks in the first and second groups, respectively (P<0.01). There was no significant difference in the functional outcome at 12 weeks, as assessed by the DASH score.

Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radial fractures.

The use of volar locking compression plates for the treatment of fractures of the distal radius is becoming increasingly popular because of the stable biomechanical construct, less soft-tissue disturbance and early mobilisation of the wrist. A few studies have reported complications such as rupture of flexor tendons. We describe three cases of rupture of extensor tendons after the use of volar locking compression plates. We recommend extreme care when drilling and placing the distal radial screws to prevent damaging the extensor tendons.

Dorsal plating for displaced intra-articular fractures of the distal radius.

Thirty patients with a mean age of 42 years and a dorsally displaced intra-articular fracture of the distal radius were treated by dorsal plating (Forte, PI and AO T plates). Twenty-eight required autogenous iliac crest bone graft. Mobilisation was started at 1-2 weeks and patients were left free by 6-8 weeks. At a minimum of 6 months (mean 11 months) functional outcomes were excellent or good in 93% according to the Gartland and Werley score and 60% according to Green and O'Briens modified score. The mean time taken to return to work was 10 weeks. At the final follow-up, three patients had intra-articular steps, two of <1mm and one of <2mm. Four patients had five major complications. One extensor tendon rupture, one reflex sympathetic dystrophy (RSD), one significant radial shortening requiring a Darrachs' procedure, one painful and incongruent distal radio-ulna joint (DRUJ) also requiring a Darrachs' and one early subluxation of the DRUJ requiring re-operation. Eleven patients had plates removed. The indications for this was either irritation of extensor tendons, restriction of movement, as part of the treatment of one of the above complications or as part of the initial treatment protocol. In these high energy injuries in the younger age group there exists no ideal solution. Internal fixation allows more predictable restoration of anatomy and early return to function.

The changing epidemiology of acute and subacute haematogenous osteomyelitis in children.

We have reviewed the incidence of bacteriologically or radiologically confirmed acute haematogenous osteomyelitis in children under 13 years of age resident in the area of the Greater Glasgow Health Board between 1990 and 1997. In this period there was a fall of 44% in the incidence of both acute and subacute osteomyelitis, mainly involving the acute form (p = 0.005). This mirrors the decline of just over 50% previously reported in the same population between 1970 and 1990. Using multiple regression analysis a decline in incidence of 0.185 cases per 100,000 population per year was calculated for the 28-year period (p < 0.001). Staphylococcus was the most commonly isolated pathogen (70%). Only 20% of patients required surgery and there was a low rate of complications (10%). In general, patients with a subacute presentation followed a benign course and there were no complications or long-term sequelae in this group. Haematogenous osteomyelitis in children in this area is becoming a rare disease with an annual incidence of 2.9 new cases per 100,000 population per year.

Familial congenital pseudarthrosis of the ulna.

A mother and daughter, both presented with congenital pseudarthrosis of the ulna due to neurofibromatosis. The daughter is one of identical twins, the second twin not having a pseudarthrosis. The mother's uncle also had pseudarthrosis of the tibia. This suggests a complex variable genetic inheritance pattern for pseudarthrosis in neurofibromatosis. Despite having had no treatment, the mother had minimal symptoms, minimal deformity, and no radial head dislocation.

Children's proximal phalangeal neck fractures with 180 degrees rotational deformity.

Five patients under 4 years of age with 180 degrees rotational deformity of a proximal phalangeal neck fracture are described. All cases resulted from a direct shear force to the bone coupled with a sharp withdrawal reaction of the hand. All of the children were successfully treated with open reduction and internal fixation but only after fruitless attempts at closed manipulation and an initial lack of recognition of the severity of the fracture. Each child achieved a full functional recovery of the finger with clinical and radiological union at 4 weeks.

Distal ulnar instability following wrist arthrodesis in men.

11 male patients with rheumatoid arthritis and 14 with osteoarthritis had total arthrodesis of the wrist. All patients with rheumatoid arthritis and ten (71%) of those with osteoarthritis had distal ulnar excision, two of the latter as a secondary procedure for impingement. Seven patients with osteoarthritis and none of the rheumatoid patients developed painful instability of the distal end of the ulna following excision. It is suggested that, in male patients with rheumatoid arthritis, distal ulnar excision with wrist arthrodesis produces excellent results with no complications. However, in male patients with osteoarthritis attempts should be made to avoid excessive shortening and ulnar impingement. If distal ulnar surgery is required, a procedure that does not affect the stability of the distal radio-ulnar joint should be performed rather than distal ulnar excision.

Wrist kinematics. Row, column or both?

Analysis of radiographs of 52 wrists showed that, from ulnar to radial deviation, the amount of scaphoid shortening and ulnar translation of the scaphoid varies in a normal distribution. There is a significant correlation between the two measurements, such that the more the scaphoid shortens the less it translates and vice versa. Females subjects were more likely to have greater scaphoid shortening and less translation. It is felt that carpal kinematics thus cover a spectrum from the "row" theory to the "column" theory which is normally distributed and that women are more likely to have a column type wrist. This variation may affect the result of treatment of scapholunate dissociation by techniques such as scapho-lunate fusion. A "CR index" is proposed so that the tendency of a wrist towards row or column theory can be quantified. This may be used to predict the success of some surgical procedures in the treatment of scapho-lunate dissociation.

Symptomatic cortical irregularities of the distal femur simulating malignancy.

We reviewed the records and radiographs of seven children who presented with knee pain, local tenderness over the medial femoral condyle, and radiological irregularity of the distal medial metaphysis of the femur suggestive of malignancy. In the five patients who had biopsies, histological changes were consistent with musculotendinous avulsion, and the dissection of ten cadavers confirmed the site to be the insertion of part of the adductor magnus. The recognition of this lesion and knowledge of its benign nature may avoid unnecessary anxiety and needless biopsy.

Wear patterns of the articular cartilage and triangular fibrocartilaginous complex of the wrist: a cadaveric study.

The incidence and patterns of degenerative changes within the radio-carpal joint were studied in 138 specimens of elderly cadaveric wrists. Articular cartilage wear of varying severity was seen on the distal radial and ulnar articular surfaces in 27% of cases and on the proximal row articular surfaces in 54%. Wear was most commonly seen on the radial styloid and corresponding area of the scaphoid. The triangular fibrocartilaginous complex (TFCC) was found to be degenerate or torn in 24%. Central degenerative perforation was commonly associated with articular cartilage wear on the ulnar head and the ulnar half of the lunate. No significant wear pattern was seen in those wrists with peripheral linear (i.e. traumatic) TFCC tears. Interosseous scapho-lunate and luno-triquetral ligament disruptions were found in less than 10%, suggesting that disruption of these ligaments is usually traumatic and not degenerative.