Proximal Humerus Fractures: What Alignment is Acceptable in Children 10 and Up?

BACKGROUND: Fractures of the proximal humerus in skeletally immature patients are rare, and even rarer still in individuals approaching skeletal maturity. Concepts regarding remodeling potential, amount of deformity and functional demands can guide our treatment decision making, but criteria are poorly defined. The purpose of this manuscript is to discuss the issues and the best available evidence. METHODS: A search of the English literature was carried out using PubMed to identify papers on the topic of proximal humerus fractures in skeletally immature individuals. RESULTS: The literature available on the topic of pediatric proximal humerus fractures is limited, especially regarding fractures in patients approaching skeletal maturity. Certainly, as the remodeling potential decreases and the amount of deformity and functional demand increase, the need for operative treatment increases. The exact tolerances and criteria have not been established. A variety of surgical techniques exist, and have been shown to be helpful. CONCLUSIONS: Operative treatment may be necessary in individuals approaching skeletal maturity. Concepts discussed in this paper regarding remodeling, amount of deformity and functional demand may help the surgeon to make appropriate treatment decisions. Future prospective comparative studies which are pending will hopefully shed further light on this matter.

Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment.

Proximal interphalangeal joint injuries are one of the most common injuries of the hand. The severity of injury can vary from a minor sprain to a complex intra-articular fracture. Because of the complex anatomy of the joint, complications may occur even after an appropriate treatment. This article provides a comprehensive review on existing techniques to manage complications and imparts practical points to help prevent further complications after proximal interphalangeal joint injury.

History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature.

BACKGROUND: Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient's condition and for the prevention of vascular disease and diabetic foot. OBJECTIVES: The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers. METHODOLOGY: An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications. RESULTS: Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient's condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed. CONCLUSION: Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.

The Effect of Closed Reduction of Small Finger Metacarpal Neck Fractures on the Ultimate Angular Deformity.

PURPOSE: To assess whether or not attempted closed reduction of fifth metacarpal neck fractures results in decreased fracture angulation at final follow-up. METHODS: Retrospective chart review of all patients aged 18 and older managed for isolated fifth metacarpal neck fractures between 2004 and 2014. RESULTS: Sixty-six patients managed for an isolated boxer fracture met inclusion criteria. Twenty-three patients underwent attempted reduction and 43 patients did not. Patients undergoing attempted reduction had a statistically significant improvement in fracture angulation following reduction compared with patients not undergoing attempted reduction. At final follow-up, there was no difference in fracture angle between the 2 groups. CONCLUSIONS: Closed reduction and splint immobilization of fifth metacarpal neck fractures was not an effective means of maintaining a significant improvement in fracture alignment upon healing. Other means, such as closed reduction with pin fixation or open reduction internal fixation, should be considered when maintenance of reduction is desired. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Ulnar Nerve Repair With Simultaneous Metacarpophalangeal Joint Capsulorrhaphy and Pulley Advancement.

PURPOSE: To evaluate the validity of performing a static anti-claw procedure (metacarpophalangeal joint volar capsulorrhaphy and A1 and A2 pulley release) at the time of ulnar nerve repair for acute or chronic lacerations to prevent development of claw hand deformity and disability or to correct them. METHODS: We present a case series of 14 patients for whom metacarpophalangeal joint capsulorrhaphy and pulley advancement were done at the time of ulnar nerve management. Direct nerve repair was performed in 10 patients, nerve grafting in 2, neurolysis in 1, and combined direct repair and anterior interosseous nerve transfer in 1. Outcome measurements included assessment of claw hand correction and sequence of phalangeal flexion according to modified evaluation criteria of Brand and motor recovery of ulnar nerve function using the British Medical Research Council (MRC) scale. RESULTS: Average follow-up was 39 months. At 3 months, 12 patients had good and 2 had fair claw hand correction. At 6 months, 2 patients had excellent, 10 patients had good, and 2 patients had fair correction. At final follow-up, 13 patients had good to excellent correction and 1 had fair correction. Motor recovery of the intrinsic muscles was rated from 2 to 5 according to the MRC scale. CONCLUSIONS: This technique is simple and effective. It acts as an internal orthosis during recovery of sufficient strength of the intrinsic muscles. In cases of incomplete recovery of the intrinsic muscles (up to MRC grade 2), it may eliminate the need for secondary surgery to correct a claw hand deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A cross-sectional electromyography assessment in linear scleroderma patients.

BACKGROUND: Muscle atrophy and asymmetric extremity growth is a common feature of linear scleroderma (LS). Extra-cutaneous features are also common and primary neurologic involvement, with sympathetic dysfunction, may have a pathogenic role in subcutaneous and muscle atrophy. The aim was investigate nerve conduction and muscle involvement by electromyography in pediatric patients with LS. METHODS: We conducted a retrospective review of LS pediatric patients who had regular follow up at a single pediatric center from 1997-2013. We selected participants if they had consistently good follow up and enrolled consecutive patients in the study. We examined LS photos as well as clinical, serological and imaging findings. Electromyograms (EMG) were performed with bilateral symmetric technique, using surface and needle electrodes, comparing the affected side with the contralateral side. Abnormal muscle activity was categorized as a myopathic or neurogenic pattern. RESULTS: Nine LS subjects were selected for EMG, 2 with Parry-Romberg/Hemifacial Atrophy Syndrome, 7 linear scleroderma of an extremity and 2 with mixed forms (linear and morphea). Electromyogram analysis indicated that all but one had asymmetric myopathic pattern in muscles underlying the linear streaks. Motor and sensory nerve conduction was also evaluated in upper and lower limbs and one presented a neurogenic pattern. Masticatory muscle testing showed a myopathic pattern in the atrophic face of 2 cases with head and face involvement. CONCLUSION: In our small series of LS patients, we found a surprising amount of muscle dysfunction by EMG. The muscle involvement may be possibly related to a secondary peripheral nerve involvement due to LS inflammation and fibrosis. Further collaborative studies to confirm these findings are needed.

Night-time immobilization of the distal interphalangeal joint reduces pain and extension deformity in hand osteoarthritis.

OBJECTIVE: DIP joint OA is common but has few cost-effective, evidence-based interventions. Pain and deformity [radial or ulnar deviation of the joint or loss of full extension (extension lag)] frequently lead to functional and cosmetic issues. We investigated whether splinting the DIP joint would improve pain, function and deformity. METHODS: A prospective, radiologist-blinded, non-randomized, internally controlled trial of custom splinting of the DIP joint was carried out. Twenty-six subjects with painful, deforming DIP joint hand OA gave written, informed consent. One intervention joint and one control joint were nominated. A custom gutter splint was worn nightly for 3 months on the intervention joint, with clinical and radiological assessment at baseline, 3 and 6 months. Differences in the change were compared by the Wilcoxon signed rank test. RESULTS: The median average pain at baseline was similar in the intervention (6/10) and control joints (5/10). Average pain (primary outcome measure) and worst pain in the intervention joint were significantly lower at 3 months compared with baseline (P = 0.002, P = 0.02). Differences between intervention and control joint average pain reached significance at 6 months (P = 0.049). Extension lag deformity was significantly improved in intervention joints at 3 months and in splinted joints compared with matched contralateral joints (P = 0.016). CONCLUSION: Short-term night-time DIP joint splinting is a safe, simple treatment modality that reduces DIP joint pain and improves extension of the digit, and does not appear to give rise to non-compliance, increased stiffness or joint restriction. TRIAL REGISTRATION: clinical trials.gov, http://clinicaltrials.gov, NCT01249391.

Reconstruction of the burned hand.

This article summarizes the initial management of acute burn injuries to the hand, in addition to treatment and reconstructive options. The goal of treatment for a burn injury to the hand is primarily a functional hand. This is best achieved by appropriate early treatment, the right selection from a wide range of possible reconstructive procedures, and focused occupational hand therapy.

Efficacy of median nerve recurrent branch neurectomy as an adjunct to ulnar motor nerve neurectomy and wrist arthrodesis at the time of superficialis to profundus transfer in prevention of intrinsic spastic thumb-in-palm deformity.

PURPOSE: The superficialis to profundus (STP) tendon transfer is an effective procedure to correct a spastic clenched fist deformity in a nonfunctional upper extremity. An intrinsic thumb-in-palm (TIP) deformity, caused by increased activity in the adductor pollicis and flexor pollicis brevis muscles, commonly becomes apparent after an STP procedure. The goal of this study was to investigate the efficacy of median nerve recurrent branch neurectomy, done at the time of STP and in concert with an ulnar motor nerve neurectomy and wrist arthrodesis, in the prevention of an intrinsic TIP deformity caused by spastic thenar muscles. METHODS: We retrospectively evaluated a consecutive series of 23 patients with upper motor neuron syndrome who underwent an STP transfer performed by a single surgeon at our institution. Group 1 included 11 consecutive patients who underwent an STP, ulnar nerve motor branch neurectomy, and wrist arthrodesis. Group 2 included 12 consecutive patients who underwent the same procedures with the addition of a neurectomy of the recurrent median nerve. We examined outcomes including development of a postoperative intrinsic TIP deformity, resolution of hygiene issues, and the need for additional surgery to correct the remaining deformities. RESULTS: Patients were observed for an average of 16.1 months. In group 1, 5 of 11 patients developed an intrinsic TIP deformity, compared with 2 of 12 in group 2. Hygiene-related issues resolved in 8 of 11 patients in group 1 and 10 of 12 patients in group 2. There were no wound infections. In the 7 patients with postoperative intrinsic TIP deformity (5 in group 1 and 2 in group 2), 5 elected to have additional surgery. Of the 7 patients, 2 declined additional surgery because their deformities were mild and their hygiene issues had resolved. CONCLUSIONS: Median nerve recurrent branch neurectomy appears to be a useful adjunct to STP with ulnar motor branch neurectomy and wrist arthrodesis in the prevention of an intrinsic TIP deformity in the nonfunctional hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The clinical effectiveness of static resting splints in early rheumatoid arthritis: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of static resting splints in early RA. METHODS: A multicentre, randomized, trial was conducted. Patients (n = 120) received either static resting splints [positioned with the wrist in neutral, MCP joint (MCPJ) and IP joint (IPJ) in a maximum of 60 degrees and 30 degrees of flexion, respectively] plus standardized occupational therapy or standardized occupational therapy alone. Change in grip strength (Ns), structural impairment (MCPJ ulnar deviation), applied dexterity (Button Board), self-report hand ability [Michigan Hand Outcomes Questionnaire (MHQ)], hand pain and morning hand stiffness were assessed at 0 and 12 months. RESULTS: Data for 56 (97%) splinted and 60 (97%) control group patients were analysed. Splint wear adherence was moderate; 24.5% 'never wore' the splints. The adjusted mean difference between groups for handgrip was -14.2 Ns (P = 0.342; 95% CI -43.7, 5.4); MCPJ ulnar deviation -1.1 degrees (P = 0.657; 95% CI = -6.2, 3.9); dexterity 0.1 s (P = 0.975; 95% CI = -6.6, 6.8) and self-report ability -3.0 on the MHQ score (P = 0.426; 95% CI -10.5, 4.5). Pain scores were unchanged in either group (P = 0.15). The occurrence of morning hand stiffness was reduced in a small group of splinted patients (P = 0.021), but the duration shortened in control patients (P = 0.010). CONCLUSIONS: There was no significant difference between the two interventions on grip strength, deformity, hand function and pain. The data favoured the control group and this study suggests that resting splints should not be used as a routine treatment of patients with early RA.

[What was found in deformities of leprosy patients from the view-point of orthopedics?].

No more deformities which are the cause of social stigma by early detection and chemotherapy! Let patients learn how to avoid getting deformed to keep normal ADL & QOL. Fight against the nerve damage and stop the progressive deformities by organizing the team approach. Instead of intense efforts of taking care by well organized team work, deformities are resulted inevitably in some cases. Let their deformities be out of the way of their keeping normal community lives without any prejudice, respecting their human rights and dignity.

Splinting the hand in the functional position after brain impairment: a randomized, controlled trial.

OBJECTIVE: To evaluate the effects of 4 weeks of hand splinting on the length of finger and wrist flexor muscles, hand function, and pain in people with acquired brain impairment. DESIGN: Randomized, assessor-blinded trial. SETTING: Rehabilitation center in Australia. PARTICIPANTS: Twenty-eight adults with acquired brain impairment, all within 6 months of the first injury. There was 1 withdrawal. INTERVENTIONS: Subjects in both experimental (n=17) and control (n=11) groups participated in routine therapy-motor training for upper-limb use and upper-limb stretches-5 days a week. The experimental group also wore an immobilizing hand splint in the functional position (10 degrees -30 degrees wrist extension) for a maximum of 12 hours each night for the duration of the 4-week intervention period. MAIN OUTCOME MEASURES: The length of the wrist and extrinsic finger flexor muscles was evaluated by measuring the torque-controlled range of wrist extension with the fingers extended. Functional hand use was evaluated with the Motor Assessment Scale. Pain was evaluated with a visual analog scale. RESULTS: The effects of splinting were statistically nonsignificant and clinically unimportant. At follow-up, estimates of treatment effects slightly favored the control group: range of motion at the wrist favored controls by 2 degrees (95% confidence interval [CI], -7.2 degrees to 3.2 degrees ), function favored controls by 0.2 points (95% CI, -2.7 to 2.3), and pain favored the experimental group by 1cm (95% CI, -4.6 to 2.2). CONCLUSIONS: An overnight splint-wearing regimen with the affected hand in the functional position does not produce clinically beneficial effects in adults with acquired brain impairment.

The optimal management of pediatric steam burn from electric rice-cooker: STSG or FTSG?

The steam burn caused by an electric rice-cooker is a unique mode of burn injury in Asian countries, especially Korea and Japan. This type of burn injury is characterized by 1) occurring most frequently on the volar aspect of the hand in toddlers younger than 2 years of age (92.8%); 2) the depth of burns are normally deep second-degree to third-degree (98%) and usually need surgery at the time of injury; 3) flexion contractures of multiple finger joints and web space contracture are common sequelae. We hypothesized that primary full-thickness skin graft (FTSG) would give more reliable results and eliminate the late reconstructive procedures. Between January 1997 and September 1999, 36 patients underwent primary FTSG, and the results of this primary FTSG group were compared with 124 patients who were treated with split-thickness skin graft (STSG; 79/124; 63.7%) or by conservative management (45/124; 36.3%), and readmitted for the correction of hand deformities between September 1995 and September 1999. In the primary FTSG group, 11.1% (4/36) of mild web contractures and 5.5% (2/36) of finger joint contractures were documented, and these did not require the reconstructive procedure during a follow-up period of 8.8 +/- 4.8 months. In 124 patients of the primary STSG or conservative group, the mean time interval to reoperation was 8.9 +/- 4.0 months and all patients received FTSG for correction of late hand deformities. In a retrospective study of the primary STSG group, 42 of 53 patients (79.2%) received reconstructive procedure during a 5-year follow-up period. In this report, we introduce the nature of steam burn caused by electric rice-cooker and propose that primary FTSG may be a reliable method for the treatment of this more severe type of acute burn in pediatric patients.

Prevention of the parrot beak deformity in fingertip injuries.

The nail is supported by the dorsal tuft of the terminal phalanx. Following distal fingertip trauma, varying amounts of nail support may be lost resulting in the nail curving palmarwards. This curvature is dependent upon the degree of bony loss, the amount of remaining nail bed and the degree of scar contracture at the hyponychial-pulp interface. The parrot beak or hooked nail deformity is most commonly caused by tight closure of a fingertip amputation and excessive palmar tension at the hyponychial-pulp suture line. A simple technique using a hypodermic needle, that eliminates tension from the suture line at the fingertip pulp-hyponychial interface and prevents hooked nail deformity is described. This allows healing to take place without any palmarwards pull of the scar and a subsequent parrot beak deformity.

Disabilities in multibacillary leprosy following multidrug therapy with and without immunotherapy with Mycobacterium w antileprosy vaccine.

A vaccine based on autoclaved Mycobacterium w was administered, in addition to standard multidrug therapy (MDT), to 157 bacteriologically positive, lepromin-negative, multibacillary leprosy patients supported by a well-matched control group of 147 patients with similar type of disease who received a placebo injection in addition to MDT. The MDT was given for a minimum period of 2 years and continued until skin-smear negativity, while the vaccine/placebo was given at 3-month intervals up to a maximum of 8 doses in the initial 2 years. The overall incidence of type 1 and type 2 reactions and neuritis during treatment and follow up was nearly equal in the patients in the vaccine and placebo groups; the differences were not statistically significant. The occurrence of disabilities, such as anesthesia, trophic ulcers, claw hand and grade 3 deformities, were not different statistically in the vaccine and placebo groups, an observation valid both for deformities present at induction and for those which developed during the course of therapy and surveillance. A statistically significant difference was observed in the recovery of newly developed trophic ulcers; recovery was quicker in the vaccine group. The recovery rate for motor deformities was marginally higher in the vaccine group, although not significant (p = 0.068) statistically. There was a statistically significant reduction in the incidence of grade 3 deformities following MDT with and without immunotherapy. To conclude, the addition of vaccine to MDT did not precipitate neuritis or deformities over and above that encountered with MDT alone, although it did accelerate bacteriological clearance, histopathological upgrading, conversion to lepromin positivity, and clinical improvement.