Unusual problems of the athlete's elbow, forearm, and wrist.

Early in their medical training physicians often are told, "When you hear hoofbeats, don't think of zebras." Such sage advice is helpful when facing the formidable challenges of information acquisition early on. Later, however, we must be familiar and consider these uncommon conditions when entrusted with the responsibility of properly caring for our patient athletes. This is particularly true in the athlete presenting with symptoms or findings disproportionate to his or her injury, or when symptoms persist despite seemingly appropriate treatment. A high index of suspicion and attention to radiographs and further appropriate work-ups result in detection of most occult unexpected lesions.

Metallic wear debris in acetabular osteolysis in a mechanically stable cementless total hip replacement: report of a case.

Wear debris has evolved as the primary etiology of mechanical loosening of cemented as well as uncemented total hip arthroplasty. Osteolysis results from particle formation, and this has been most commonly reported to be secondary to polyethylene wear debris. This article demonstrates that metallic particle debris will also result in significant osteolysis. The two sources in this case are cobalt-chromium (Co-Cr) particles from the acetabular component and titanium-alloy (Ti) particles from the Morse taper junction and the Ti-alloy femoral head. However, it is likely that polyethylene debris also contributed to the osteolysis, because a titanium head was used and we know this results in increased poly wear.

Magnetic resonance appearance of peripheral nerve sheath tumors.

Magnetic resonance imaging (MRI) was used to evaluate 22 histologically proven peripheral nerve sheath tumors, approximately two-thirds of which arose in the lower extremity. The histologic distribution was as follows: 12 schwannomas, 7 neurofibromas, and 3 malignant peripheral nerve sheath tumors (2 of which occurred in patients with neurofibromatosis). Most lesions demonstrated an intermediate to moderately bright signal on T1-weighted images and were minimally inhomogeneous. All lesions were moderately bright on proton-density-weighted images and bright on T2-weighted images, again with variable inhomogeneity. The extent of the tumor was best assessed on proton-density- and T2-weighted images. Smooth margins were noted in 19 lesions. Of the 3 remaining lesions, 2 were malignant (but had been subjected to biopsy prior to MRI), and the other lesion was a plexiform neurofibroma. MRI accurately determined the relationship between the lesion and the adjacent neurovascular structures and muscles, thereby assisting surgical management. On MRI, 5 lesions demonstrated coexistent subtle muscle atrophy along the longitudinal axis of surrounding or distally innervated musculature. This latter finding, together with the presence of a tumor in the vicinity of a large nerve trunk, suggests a peripheral nerve sheath neoplasm.

Magnetic resonance imaging of peripheral soft tissue hemangiomas.

Ten patients with soft tissue hemangiomas outside the central nervous system were studied with MR imaging. Eight patients were studied at 1.5 Tesla (T) with T1-weighted and triple echo T2-weighted sequences. Two additional patients were imaged on a 0.5-T system. The MR images were correlated with images from other modalities. Histologic diagnosis was obtained in all cases. It was found that prolonged T2-weighted imaging together with standard spin echo T1 and T2 pulse sequences is a good substitute for contrast-enhanced CT and arteriographic evaluation of soft tissue hemangiomas.

Arthrodesis of small joint of the hand: a rapid and effective technique.

Seventy-six patients underwent 103 arthrodeses of digital joints of the hand to treat deformity, pain, or instability. Each fusion was done by means of a surgical technique that allowed for proper positioning with minimal shortening. No bone graft was used. Only one joint failed to fuse. Bony union was present in 10 weeks or less in 86% of the digits. External immobilization was not used in one third of the joints, primarily low-demand patients with rheumatoid arthritis. There were two superficial pin tract infections that healed after pin removal and a course of oral antibiotics. This surgical technique proved to be technically simple and allowed for easily adjusted positioning of each joint without multiple osteotomies or excess shortening.

Tumoral calcinosis in multiple digits: a case report.

Tumoral calcinosis usually appears in the vicinity of large joints, and its appearance in the fingers must be quite rare since no reports of such an occurrence have been found. A case report of the presence of tumoral masses of hydroxyapatite in multiple digits is presented. No causative or related metabolic or collagen-vascular disease was identified, and the patient remains in good health.

Upper extremity neuropathies after cardiac surgery.

Although coronary artery bypass grafting is a common procedure, there can be significant postoperative morbidity. The occasional finding of unexplained postoperative neuropathy in these patients prompted this study. Fifty-three patients who had cardiac surgery that used the standard median sternotomy were studied prospectively. Detailed sensory and motor testing and intraoperative measurement of the distance of sternal retraction and duration of cardiopulmonary bypass were recorded. Twenty patients (37.7%) exhibited postoperative motor and sensory neuropathies, all of which involved the ulnar nerve. Five patients who were studied with electromyography and nerve conduction evaluations exhibited evidence of brachial plexus injury. The average duration of symptoms was 2.3 months, but several patients have long-term unresolved symptoms. Previous neuropathies, wide retraction of the sternum, and long cardiopulmonary pump runs seem to predispose to such injury, which appears to involve the brachial plexus. Anatomic reasons for such findings are offered.

A morphologic study of the relationship of collateral ligaments to growth plates in the digits.

The precise origin and insertion of collateral ligaments to metacarpals and phalanges prior to growth plate closure is not clearly described in textbooks or journals. This study delineates such attachments by gross dissection and microscopic evaluation. Middle and distal phalangeal attachments are to epiphyses and metaphyses, whereas attachments at the metacarpophalangeal joint are almost entirely to the epiphyses of metacarpal and proximal phalanges. The clinical significance of these differences is not known.

Tumors of the hand.

A review of 129 hand tumors suggests that diagnosis of a swelling in the hand is often uncertain because of the close proximity of many different tissues in a small volume. Histologic diagnosis is necessary to assure appropriate treatment; excisional biopsy should be done whenever possible; if the lesion is benign, treatment has been completed; in the event the lesion is malignant, further treatment will not have been materially compromised. The margin of normal tissue around malignant lesions often precludes treatment of such tumors of the hand by ray resection or wide local excision because adequate wide excision will frequently leave nothing functional. Attempts at wide local excision are ofter compromised by the surgeon's natural desire to preserve function; this frequently results in incomplete removal of the tumor. The function preserved will be of little benefit to a patient with widespread metastases.