Factitious disorders of the upper extremity.

Factitious disorders of the upper extremity can manifest in many different forms; therefore, it is critical to recognize warning signs in the history and examination indicating that the patient may be creating the symptoms and physical manifestations of the presenting illness. These disorders present in such predictable patterns as lymphedema, Secretan syndrome, ulcerations and wound manipulation, clenched fist, subcutaneous emphysema, pachydermodactyly, nail deformities, and self-mutilation. Management recommendations include assigning therapeutic responsibility to one person and the involvement of a multidisciplinary team. Thorough documentation is essential for the protection of both the patient and the treating physician. Treatment of patients with factitious disorders of the upper extremity requires patience and insight to avoid being manipulated into performing unnecessary surgical procedures.

Ossifying lipoma of c1-c2 in an adolescent.

BACKGROUND: Ossifying lipomas, characterized by their independence of bony connection to the skeleton, are extremely rare benign neoplasms. They have primarily been described in adults older than 50 years of age and occur in the head and neck region. The etiology is unknown. Excision is the preferred treatment. The objective of this study is to report the case of a rare ossifying lipoma immediately anterior to C1 to C2, requiring a transoral approach for excision. METHODS: The case of an adolescent with a retropharyngeal mass is described. RESULTS: A 15-year-old female patient presented with an asymptomatic parapharyngeal mass detected on routine physical examination. Computed tomography and magnetic resonance imaging noted a calcified, left-sided, parapharyngeal mass, approximately 3×2×2 cm, anterior to C1 and C2, most consistent with a benign osseous lesion. A transoral approach was used to excise the mass. Histologic examination demonstrated an ossifying lipoma. Postoperative imaging confirmed complete excision. The postoperative course was unremarkable, and the patient has had no recurrence at 6-month follow-up. CONCLUSIONS: This case demonstrates that a transoral approach to a lesion anterior to C1 to C2 in an adolescent can be safe, complete, and effective. LEVEL OF EVIDENCE: Case Report, level 5.

Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients.

BACKGROUND: The brachial artery is the most common vascular injury encountered in upper extremity trauma. If not treated promptly, it can result in compartment syndrome (CS) and long-term disability. Here, we report an institutional experience of traumatic brachial artery injuries and establish risk factors for the development of upper extremity CS in this setting. METHODS: A retrospective review of 139 patients with traumatic brachial artery injury from 1985 to 2001 at a single institution. Patients were divided into two cohorts, those with evidence of CS and those without CS (NCS), for comparison. RESULTS: One hundred thirty-nine patients presented with traumatic brachial artery injuries (mean age, 28.4 years). Twenty-nine patients (20.9%) were diagnosed with upper extremity CS, and 28 of these patients underwent fasciotomy on recognition of their CS. Seven patients (6.4%) in the NCS cohort underwent fasciotomy as a result of absent distal pulses on initial examination. Mean follow-up was 51.6 days. Two patients required revision of their arterial repair, and one patient underwent amputation. The risk of CS was increased in the presence of combined arterial injuries (p = 0.03), combined nerve injuries (p = 0.04), motor deficits (p < 0.0001), fractures, and increased intraoperative blood loss (p = 0.001). Multivariate logistic regression performed on these variables revealed that elevated intraoperative blood loss, combined arterial injury, and open fracture were independent risk factors for the development of CS (OR 1.12, 5.79, and 2.68, respectively). CONCLUSION: Prompt evaluation and management of traumatic brachial artery injuries is important to prevent CS, which can lead to functional deficits. In the setting of combined arterial injury, open fracture, and significant intraoperative blood loss, prophylactic fasciotomy should be considered.

A prognostic model for the risk of development of upper extremity compartment syndrome in the setting of brachial artery injury.

A potentially devastating sequela of brachial artery injury in the setting of upper extremity trauma is the development of compartment syndrome (CS). We performed a retrospective review of 139 trauma patients with brachial artery injury from 1985-2001. Objective characteristics of each case were extracted and analyzed using multivariate logistic regression. Three variables were found to be significant in the final model: estimated intraoperative blood loss as a continuous variable, and presence of a multiple arterial injury and presence of an open fracture as categorical variables. Odds ratio were 1.12, 5.79, and 2.68, respectively. We used these variables to create a summative score for the development of CS with weights assigned proportional to the adjusted odds ratio. Odds of having CS for subjects in group 2 and group 3 are 5.3 and 15.1 times the odds for subjects in group 1, respectively. Applying multivariate regression analysis to the largest series of brachial artery injuries to date, we have developed a predictive scoring model of CS.

The humeral head as a potential donor source for osteochondral allograft transfer to the knee.

This study aimed to determine whether osteochondral allograft plugs from the humeral head are a good topographic match to recipient sites on the femoral condyle. If so, the donor pool for allograft osteochondral transplantation to the knee may increase. Simulated osteochondral grafts of 1-cm, 1.5-cm, and 2-cm diameters were taken from the surface map of the humeral heads and superimposed and optimized on recipient sites of identical size on the femoral condyles. Primary measurement criteria included contour mismatch and circumferential step-off. These measurements increased with donor plug size. For the 1-cm and 1.5-cm plugs, the lowest mean mismatch (0.068 mm and 0.110 mm, respectively) and step-off (0.057 mm and 0.154 mm, respectively) occurred at the 30 degree medial position. For the 2-cm plugs, the lowest mean mismatch (0.183 mm) and step-off (0.227 mm) occurred at the 60 degree lateral position. Although 1-cm osteochondral plugs were a good topographic match to the recipient sites, the 2-cm plugs had a mismatch approaching 0.5 mm, an offset with a demonstrated peak contact pressure > 40% higher than normal. The topographic match of the humeral head suggests it is a potential donor source for osteochondral allograft transfer to the distal femur.

Dorsoradial ligament imbrication for thumb carpometacarpal joint instability.

UNLABELLED: Dorsoradial ligament imbrication is a direct and effective alternative to ligament reconstruction or metacarpal osteotomy in patients with symptomatic thumb carpometacarpal (CMC) joint instability. This procedure is performed by imbricating either the trapezial or the metacarpal attachment of the dorsoradial ligament with the use of a suture anchor. The procedure is indicated in the setting of chronic hyperlaxity or instability of the thumb CMC joint. Significant arthritic changes in the thumb CMC joint are a contraindication for this procedure. We present our technique along with an anatomic dissection to demonstrate the ligament and surgical procedure on an anatomic specimen. We also present results from 3 patients who underwent this technique with images and clinical results for 3 patients with long-term follow-up. LEVEL OF EVIDENCE: Level IV-Therapeutic.

Proximal interphalangeal joint fracture dislocations in professional baseball players.

Treatment of professional baseball players with PIP injuries requires careful evaluation and prompt treatment. Stability of the injury dictates treatment and return to play. The majority of injuries can be managed with minimal splinting or buddy taping, but the most complex injuries require operative intervention to ensure stable reduction. Consideration of players' position and handedness is important in determining return to practice and play.

The use of thermal shrinkage for scapholunate instability.

Scapholunate interosseous ligament (SLIL) instability is the most common form of carpal instability. There is a lack of consensus among hand surgeons as to the appropriate treatment of various stages. This article reviews the background and results of thermal treatment of predynamic instability of the SLIL. Case examples are discussed as well as a series of patients treated with our protocol for this injury.

Pilomatrixoma of the forearm: a case report.

Pilomatrixoma is a benign neoplasm derived from hair follicle matrix cells. Involvement of the upper extremities is relatively uncommon and can be mistaken for malignancy. We present the case of a 52-year-old woman with a pilomatrixoma of the forearm, and we review the literature regarding pilomatrixomas in the upper extremity.

Does neck/liner impingement increase wear of ultrahigh-molecular-weight polyethylene liners?

We explore the hypothesis that repetitive impingement increases wear of ultrahigh-molecular-weight polyethylene inserts. During revision total hip arthroplasty, 113 acetabular components were retrieved and examined for impingement, backside wear, and articular wear. Sixty percent of acetabular liners showed evidence of prosthetic impingement, with moderate or severe damage to the rim in 32%. Moderate or severe backside damage was present in 31%. Backside wear was found in 61% (22/36) of liners exhibiting impingement vs 16% (12/73) of liners without impingement (P < .0001). The average articular wear rate of liners with moderate/severe impingement damage was 159 +/- 42 mm(3)/y, compared with 70 +/- 21 mm(3)/y for liners with no/mild impingement damage (P = .02). Repetitive impingement frequently occurs after total hip arthroplasty and leads to a multitude of adverse events, including motion between the liner and the acetabular shell.

Cracking and impingement in ultra-high-molecular-weight polyethylene acetabular liners.

The purpose of this study was to determine the prevalence of crack formation in conventional ultra-high-molecular-weight polyethylene cups and its association with rim impingement, oxidation, and time in situ. One hundred twenty acetabular cups were retrieved during revision total hip arthroplasty. In 40% (48/120) of the retrieved specimens, multiple subsurface cracks of several millimeters in length were revealed by transillumination. In 5 specimens, full thickness cracks led to fragmentation of the liner before revision. Thirty-eight (32%) liners had regions of moderate to severe impingement damage to the rim; cracks were initiated at the site of impingement in all but 1 liner (P < .0001). Cracks commonly occur in conventional ultra-high-molecular-weight polyethylene liners, often after neck impingement and almost always in association with oxidation of the polymer.