Importance of detection of capitellar cartilage injuries concomitant with isolated radial head fractures: A retrospective clinical study.

OBJECTIVE: This study aimed to analyze the injury pattern and clinical importance of concomitant capitellar cartilage defects (CCDs) among patients treated surgically for radial head fracture (RHF). METHODS: A total of 74 patients who were treated surgically for isolated RHFs were retrospectively reviewed. Of these, 12 patients with CCDs (16.2%) were classified as Group I (10 men; mean age, 41.3±12.8 years) and the remaining 62 patients without CCD as Group II (control group) (48 men; mean age, 50.8±13 years). The mean follow-up was 21.3±3.2 months in Group I and 18.7±6.4 in Group II. In Group I, 11 patients underwent open reduction and internal fixation, whereas 1 patient was treated by radial head resection. The preoperative range of motion (ROM) was recorded; the severity of RHF was assessed using the Mason classification. The location, size, and thickness of CCD injuries at the time of surgery were also documented. At the final follow-up, radiological assessment was performed to determine the bone union, and clinical measurements, including ROM and the Mayo elbow performance score (MEPS), were performed. The clinical features of the 2 groups were statistically analyzed. RESULTS: In Group I, 10 patients showed limited forearm rotation. CCD was located posterolaterally in 11 patients and anterolaterally in 1 patient. At the final follow-up, 11 patients from Group I who underwent open reduction and internal fixation showed complete union of RHF and full recovery of pronation and supination. According to the MEPS, 9 patients exhibited excellent results, and 3 patients exhibited good results. In Group I, RHFs were classified as Mason type II in 7 patients (58.3%) and type III in 4 patients (58.3%). In Group II, RHFs were type II in 45 patients (72.6%) and type III in 17 patients (27.4%). In comparative analyses, there was a significant difference in age (41.3±12.8 versus 50.8±13.0, p=0.041) between the 2 groups. Preoperative pronation/supination was higher in Group II (131.7±36.2) than in Group I (106.3±31.6) (p=0.021). There were no significant differences in sex (p=0.097), follow-up period (p=0.326), Mason type (p=0.482), preoperative extension/flexion (102.3±43.3 [Group I] versus 107.6±44.9 [Group II]) (p=0.584), final follow-up extension/flexion (133.3±10.7 [Group I] versus 126.9±21.2 [Group II]) (p=0.384), pronation/supination (151.2±9.1 [Group I] versus 151.2±13.3 [Group II]) (p=0.558), and the MEPSs (92.9±6.6 [Group I] versus 93.3±7.5 [Group II]) (p=0.701). CONCLUSION: If a thorough physical examination of a patient with RHF reveals limited forearm rotation, effort must be made to identify the cause, and the possibility of CCD must be considered. Moreover, there is a need for careful observation during RHF surgery for not only fracture reduction or fixation but also possible CCD. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Carpal Tunnel Syndrome Caused by Lipofibromatous Hamartoma of the Median Nerve.

Lipofibromatous hamartoma (LFH) is a rare tumor of the peripheral nerves, which usually involves the median nerve. The authors reported on two rare cases of carpal tunnel syndrome due to LFH of the median nerve. A 49-year-old female patient complained of the mass and symptoms consistent with LFH. Magnetic resonance imaging (MRI) showed typical LFH findings. The symptoms were successfully ameliorated with carpal tunnel release and external neurolysis. A 37-year-old female patient complained of weakening thumb abduction and the mass where the MRI showed atypical findings. Opponensplasty and debulking operations were performed after which thumb abduction was improved; however, neurological sequelae remained. LFH of the median nerve is managed on a case-by-case basis as treatment guidelines are not very clearly defined yet. However, the less invasive treatment such as carpal tunnel release and external neurolysis than more aggressive surgical treatment should be recommended as a treatment option.

Two-dimensional Morphological Characteristics of the Distal Radius on Axial Magnetic Resonance Image and the Effects on Distal Screw Length.

BACKGROUND: Detection of dorsal cortical penetration of distal locking screws is difficult owing to the irregular shape of the dorsal surface of the distal radius. This study was designed to analyze two-dimensional morphological characteristics of the distal radius on axial magnetic resonance image, and to suggest a guideline for evaluation of screw length in distal radius fractures on the fluoroscopic or plain X-ray true lateral image. METHODS: Anteroposterior length and lateral width of the distal radius, distance between the highest and the lowest point of the dorsal cortex (deceptive length), and widths of the first to second (hazard zone) and the third to fifth extensor compartments (safe zone) at the Lister tubercle level were measured on 104 axial magnetic resonance images by two hand surgeons. RESULTS: The mean length and width of the distal radius at the Lister tubercle level were 22.96 mm and 30.42 mm, respectively. The mean hazard zone and safe zone widths were 8.72 mm and 19.43 mm, respectively. The mean deceptive length was 4.07 mm and the deceptive length did not have a relationship with height, sex, and age of subjects. CONCLUSIONS: We suggest that 4 mm be used as a reference value for the evaluation screw length at the safe zone. If the vertical distance between a distal screw tip and the peak of the Lister tubercle is lesser than 4 mm on a fluoroscopic or plain X-ray true lateral image, dorsal cortical penetration should be suspected. When dorsal cortical penetration at the hazard zone is suspected, both oblique or pro-supination views should be checked.

Treatment of Kienböck's disease using a fourth extensor compartmental artery as a vascularized pedicle bone graft.

BACKGROUND: Vascularized bone grafts for the treatment of Kienböck's disease may facilitate revascularization and remodeling of the avascular lunate. The aim of this study was to evaluate the radiological and clinical results obtained when a fourth extensor compartmental artery (ECA) bone graft was used to treat Kienböck's disease. METHODS: Between May 2009 and June 2012, 13 patients (6 men, 7 women) with Kienböck's disease were treated with placement of fourth ECA vascularized bone grafts. The mean patient age was 39.2 (20-58) years, and the mean follow-up period was 32.5 (12-72) months. At the time of surgery, One patient had Lichtman's stage II Kienböck's disease, 11 stage IIIA disease, and one stage IIIB disease. We measured the pre- and post-operative ranges of motion, pain, grip strength, and radiological parameters, including the carpal height ratio and the radioscaphoid angle. RESULTS: At the last follow-up, pain was significantly reduced, and grip strength had improved from 60.5% to 87.8% relative to that of the contralateral side. The mean range of motion for flexion had improved from 39° to 53° while that of wrist joint extension improved from 41° to 56°. There were little or no changes in either the carpal height ratio or the radioscaphoid angle (both p values > 0.05). CONCLUSIONS: Placing of a fourth ECA vascularized bone graft is a reliable alternative to other revascularization procedures for treatment of Kienböck's disease. Such grafting is effective, minimally invasive, and associated with a low risk of pedicle kinking. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic/IV.

Multiple etiologies of trigger wrist.

BACKGROUND: Trigger wrist, a relatively unusual condition, is a triggering at the wrist produced by wrist or finger motion. The clinical manifestations and surgical results of trigger wrist with multiple etiologies were evaluated. METHODS: From October 2008 to December 2012, this study retrospectively reviewed 15 patients diagnosed with trigger wrist. The patients comprised six men and nine women with a mean age of 44.8 years (range, 29-86 years). The mean follow-up period was 16.2 months (range, 11-30 months). RESULTS: The causes of trigger wrist were an anomalous muscle belly of the flexor digitorum superficialis (n = 5), severe tenosynovitis of the flexor tendon (n = 4), fibroma around the flexor tendon sheath (n = 2), a rheumatoid nodule (n = 1), both anomalous muscle belly and tenosynovitis (n = 1), a ganglion (n = 1), and pigmented villonodular synovitis (n = 1). Mild-to-moderate symptoms of median neuropathy without thenar muscle atrophy were present in all patients. Postoperatively, all patients recovered well with resolution of median nerve symptoms, and the wrist triggering was absent. CONCLUSIONS: Trigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic/IV.

Spontaneous anterior interosseous nerve syndrome: clinical analysis of eleven surgical cases.

The aetiology of anterior interosseous nerve (AIN) syndrome and an optimal treatment strategy remain controversial. Eleven patients with spontaneous AIN syndrome, who were treated by surgical exploration, were reviewed at a mean of 32.5 months after the operation. Eight men and three women were included in the study. None of the patients had a history of trauma and there was no evidence of a neuropathy other than AIN syndrome. Six patients showed complete paralysis of the flexor pollicis longus (FPL) and the flexor digitorum profundus of the index finger (FDS1). Five patients had incomplete paralysis, with isolated lesions of the FPL in two and the FDP1 in three. Surgery was performed 7.8 months after the onset of paralysis. The most common structure of nerve compression was a fibrous band of the flexor digitorum sublimis muscle. However, no definitive compression site or anatomic abnormality could be found in four patients. Ten of the 11 patients had recovered muscle strength above grade 4 within 12 months of the operation. Good results were obtained in 10 patients and fair in only one at final assessment. Four patients (one man and three women) raised cosmetic concerns due to excessive scar formation on the upper forearm. Surgical exploration is recommended only in cases where AIN syndrome is apparent, no other neuronal lesions are apparent, and where there was no recovery after 6 months of conservative treatment. Careful preoperative examination is essential to avoid misdiagnosis and inappropriate operation, particularly in cases of incomplete AIN syndrome.