Distal radius fractures: What are the effects of ulnar styloid fracture and face-toface rehabilitation on the functional outcome?

OBJECTIVE: This study aimed to investigate the effects of the accompanying ulnar styloid fracture and 2 different postoperative rehabilitation protocols on the final outcomes following surgical treatment of distal radius fractures. METHODS: In this retrospective study, 47 patients (11 male, 35 female; mean age=52.6 years, age range=24-85) who underwent plate fixation for distal radius fractures were divided into 4 groups based on the presence of an ulnar styloid fracture and type of rehabilitation. To evaluate clinical outcomes, wrist range of motion (ROM), grip strength, lateral pinch strength, disabilities of the arm, shoulder, and hand (DASH) questionnaire scores and visual analog scale (VAS) scores were obtained at the final follow-up. The rehabilitation exercises of the patients in groups 1 and 2 were carried out in the physical therapy room by the hand therapist during the postoperative 2 months. Patients in groups 3 and 4 were supplied with videos of the exercises of each phase and instructed to carry out those exercises at home routinely. RESULTS: Patients who received home rehabilitation programs demonstrated greater grip strength loss. Patients without accompanying ulnar styloid fractures had better DASH and VAS scores. Final wrist ROM and the duration for return to preinjury activity level did not differ among groups. CONCLUSION: This study has suggested that accompanying ulnar styloid fractures may worsen the functional outcomes after plate fixation of distal radius fractures. Home-based programs may provide patients with adequate overall wrist function with certain drawbacks compared to rehabilitation under direct supervision.

Rehabilitation protocol after suspension arthroplasty of thumb carpometacarpal joint osteoarthritis.

STUDY DESIGN: Retrospective case series. INTRODUCTION: When conservative modalities and therapies fail to control symptoms of thumb carpometacarpal (CMC) joint osteoarthritis, surgery may be indicated. PURPOSE OF THE STUDY: To present a rehabilitation protocol used in a series of patient cases after suspension arthroplasty and to evaluate outcomes. METHODS: Twenty-seven patients with CMC osteoarthritis were treated by the same arthroplasty technique and the same rehabilitation program. Patients were evaluated before and 12th week after surgery, and at the last follow-up using a visual analog scale; the Disability of the Arm, Shoulder, and Hand questionnaire; strength measurements; range of motion evaluations; and radiographic assessment. RESULTS: Average follow-up period was 31.5 months. There was a decreasing trend in both subjective scores during follow-ups (p=0.0001). Thirty-three percent and 30% improvements on radial and palmar abductions, respectively, and 29% improvement on pinch strengths were recorded at the final follow-up. Postoperative grip improvement was not preserved at the last follow-up. CONCLUSIONS: The results demonstrate a high degree of patient satisfaction suggesting the efficacy of this surgical technique and postoperative rehabilitation protocol. LEVEL OF EVIDENCE: Level 4.

Reconstruction of the first web space in symbrachydactyly using the reverse radial forearm flap.

PURPOSE: To present a new approach for the reconstruction of severe first web contractures using a distally based reverse radial forearm flap in symbrachydactyly patients. METHODS: This study included 6 hands in 5 patients. Subjective evaluation included appearance, parent satisfaction (and patient satisfaction when appropriate), and ability to perform daily activities such as thumb-index grasp and pinch at follow-up evaluations. We measured the angle between the first and second rays using a goniometer at maximum radial abduction, and pinch and grasp strengths were evaluated as an objective assessment. RESULTS: The average follow-up period was 2 years. All parents and patients were happy with the aesthetic appearance. They were completely satisfied in their daily living activities. The average first web angle measurement was 56 degrees . An average of 39 degrees of improvement of web measurement was achieved. For the unilateral 4 patients, the average pinch strength measurement was 80% of the normal contralateral hand and the grip strength was 75% of the normal contralateral hand. CONCLUSIONS: The reverse radial forearm flap was found to be a safe and simple method in the reconstruction of severe first web contractures in symbrachydactyly patients. This method provided good coverage of appropriate thickness and skin quality, and supple soft tissue that filled the first web space. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[Klippel-Feil syndrome and associated congenital abnormalities: evaluation of 23 cases]. / Klippel-Feil sendromu ve eslik eden dogumsal anomaliler: 23 olgunun incelenmesi.

OBJECTIVES: The purpose of this study was to review adult patients with Klippel-Feil syndrome. METHODS: The study included 23 male patients (mean age 20.5 years, range 19 to 27 years) with Klippel-Feil syndrome. Besides orthopedic clinical evaluation, all the patients were assessed by anteroposterior and lateral cervical flexion/extension and thoracolumbar radiographies, abdominal ultrasonography, and were subjected to systemic examinations to detect any urological, cardiological, otorhinolaryngological, neurological, and psychiatric findings. Temporal computed tomography was performed in seven patients, and cervical magnetic resonance imaging in three patients. RESULTS: Scoliosis, fusion of the cervical vertebrae (between 2-5 vertebrae), low hairline and short neck were found in all the cases. Lumbar fusion was detected in one patient. Other findings included renal agenesis (n=1), different types of hearing loss (n=9), cardiac pathologies (n=5), epilepsy (n=1), and marked (n=1) or mild (n=1) mirror movements. CONCLUSION: Patients with Klippel-Feil syndrome should be assessed for associated systemic abnormalities besides cervical fusion.

[Pedicled flap procedures for sensory restoration of the hand: long-term results]. / Elin duyu restorasyonu için pediküllü flep uygulamalari ve geç dönem sonuçlar.

OBJECTIVES: We evaluated the long-term results of patients who underwent reconstruction with pedicled flaps for soft tissue and sensory restoration. METHODS: The study included 30 patients (26 males, 4 females; mean age 33 years; range 16 to 62 years) who underwent sensory restorations of the thumb (n=24), the index finger (n=3), and the little finger (n=3). Twenty-seven patients received neurovascular island flaps and three patients received radial innervated cross-finger flaps. Disconnection-reconnection of the nerve was performed in 11 patients receiving a neurovascular island flap. Sensory evaluations were made with two-point discrimination and the Semmes-Weinstein monofilament test. The mean follow-up was 29.2 months (range 5 to 144 months). RESULTS: There were no cases of flap loss. Contractures of donor digits were seen in four patients (14.8%) treated with neurovascular island flaps. Neuroma formation was noted in two patients (18.2%) in whom the disconnection-reconnection technique was used. Static and moving two-point discrimination test results were 9.1 mm and 7.4 mm with the disconnection-reconnection technique, 8.3 mm and 7 mm with the original technique, and 10.3 mm and 8.6 mm with radial innervated cross finger flaps, respectively. Sensation was at the recipient site in all the patients who underwent disconnection-reconnection. Of those in whom the original technique was employed, nine patients (56.3%) localized sensation at the recipient site, three patients (18.8%) at the donor site, while four patients (25%) showed double sensibility. CONCLUSION: Pedicled flaps are reliable and satisfactory alternatives for soft tissue and sensory restoration of hand injuries and disconnection-reconnection of the nerve is effective in preventing double sensibility.

Sonographic evaluation of scapholunate ligament: value of tissue harmonic imaging.

PURPOSE: The aim of this study was to compare tissue harmonic imaging (THI) and conventional (fundamental) sonography in the evaluation of the scapholunate ligament (SLL). METHODS: The bilateral SLL of 3 patients with unilateral SLL rupture and the bilateral SLL of 20 volunteers without history of trauma were examined. THI findings were compared with conventional sonographic findings. RESULTS: On conventional sonographic evaluation of 43 normal wrists, the dorsal component of the SLL was partially visible in 10 of the 43 normal wrists (23%) and was completely visible in 33 of 43 (77%) normal wrists. Using THI, the SLL was visible in its entirety in 39 of 43 normal wrists (91%) and was partially visible in 4 of 43 normal wrists (9%). The mean scapholunate distance was 3.3 mm (range, 2.9-4.5 mm) in normal wrists. THI improved visualization of SLL continuity and demonstration of its fibrillar echotexture. In the 3 wrists with clinical and/or radiological evidence of SLL rupture, the SLL was not visible with conventional sonography nor THI; the mean scapholunate distance was 6.1 mm (range, 5.6-6.8 mm). CONCLUSIONS: THI improves visualization of the SLL.

Quadrilateral space syndrome caused by a humeral osteochondroma: a case report and review of literature.

Quadrilateral space syndrome (QSS) is a rare condition in which the posterior humeral circumflex artery and the axillary nerve are entrapped within the quadrilateral space. The main causes of the entrapment are abnormal fibrous bands and hypertrophy of the muscular boundaries. Many other space-occupying causes such as a glenoidal labral cyst or fracture hematoma have been reported in the literature. However, we could not find a report on classical QSS caused by an osteochondroma. The aim of this case report is to attract attention to an unusual etiology of shoulder pain, and to emphasize the importance of physical examination and x-ray imaging before performing more complex attempts for differential diagnosing.

Ultrasonographic findings in pediatric fractures.

The aim of this study was to document and analyze ultrasonographic (US) findings in different types of pediatric fractures. Thirty-nine patients, aged between 1 and 14 years, with a fracture were included in the study. Patients were classified as complete or incomplete fractures. Greenstick fractures, torus fractures and plastic deformations were considered as incomplete fractures. Ultrasonographic findings (subperiosteal hematoma, bending, cortical disruption, and reverberating echo) were analysed for each type of fracture. Subperiosteal hematoma was present in all patients in the study. Bending sign was present in all patients in the incomplete fracture group, but not present in complete fractures. Cortical disruption and reverberating echo were present in all patients with complete and greenstick fractures. In conclusion, whether the fracture is complete or incomplete, subperiosteal hematoma, together with a cortical disruption, bending sign, or reverberating echo shown on US can confirm the fracture diagnosis in children.

Reliability of the safe area for the superior gluteal nerve.

The authors investigated the reliability of the safe area, which previously was defined to prevent injury to the superior gluteal nerve during the lateral approach to the hip, and its relation to body height. The distance between the point of entry of the superior gluteal nerve into the gluteus medius muscle and the greater trochanter, in the regions which were defined as the anterior and posterior halves of the muscle, were measured in 23 cadaveric hips. There was a significant correlation between the height of the cadavers and the distance in the anterior and posterior regions. In all of the anterior regions and 78% of the posterior regions of the hips, the superior gluteal nerve as found to be in the safe area. The current study showed that the average distance between the innervation point of the gluteus medius muscle and the greater trochanter might change as a function of body height. The risk of damage to the superior gluteal nerve may be higher if the direct lateral approach to the hip is used. These data show that it is possible that the safe area is not always safe.

Modification of the extension block Kirschner wire technique for mallet fractures.

A modification of the extension block Kirschner wire technique that is used for closed reduction of mallet fractures is described. Eighteen mallet avulsion fractures of the distal phalanx treated with this modification were included in this prospective study. The fingers affected were nine small fingers, eight ring fingers, and one long finger. Surgical indications included fractures involving more than 33% of the articular surface and fractures associated with subluxation of the distal phalanx that could not be corrected by closed reduction. The average joint surface involvement was 39.8%. At followup, only one patient had pain, and that was graded as minimal. Objectively, congruous and satisfactory joint surfaces were present in 17 patients. No patient had pseudarthrosis. The average active flexion of the distal interphalangeal joint was 81.1 degrees and the average extensor lag was 1.6 degrees. Neither pin tract infections nor migration of the pins occurred. The average followup was 27.3 months. This modification increased range of motion at the distal interphalangeal joint and showed a trend toward reduced permanent extensor lag when compared with the original method. This technique should be considered when treatment of the mallet fracture is being planned using the extension block Kirschner wire technique.

Dehydroepiandrosterone as an enhancer of functional recovery following crush injury to rat sciatic nerve.

This study was designed to investigate the effect of dehydroepiandrosterone (DHEA) on the recovery of the rat sciatic nerve following crush injury. A standard hemostat system was used to create the injury, with a length of 1.5 mm in three groups of 18 animals each. In group I, the crush injury was applied without any treatment. In groups II and III, vehicle (ethylene glycol) and DHEA solutions were injected subepineurally 30 min following the crush injury. Sciatic function index (SFI), toe contracture measurement, gastrocinemius muscle weight, total number of myelinated fibers, fiber diameters, myelin thickness, and axon/fiber cross-sectional ratio were measured at 3, 6, and 12 weeks. The SFI values in the DHEA group showed a faster return to normal values confirmed at 3 and 6 weeks (P < 0.05). The number of myelinated fibers and fiber diameters at 6 and 12 weeks were significantly higher in the DHEA group (P < 0.05). In this study, the subepineural injection of DHEA following crush injury was found to enhance functional recovery of the rat sciatic nerve.

Chondroitin sulfate-coated polyhydroxyethyl methacrylate membrane prevents adhesion in full-thickness tendon tears of rabbits.

Polyhydroxyethyl methacrylate (pHEMA) membranes coated on one side with chondroitin sulfate (CS) were used to block adhesion physically and to reduce friction between healing flexor tendons and the surrounding tissue in rabbit forepaws after surgical repair. Digits with pHEMA-only, standard tendon sheath repair, and with no sheath repair were the controls. Over 12 weeks the CS-coated membranes were evaluated for joint flexion, adhesion limitation, and tendon healing progress. The membranes initially allowed for better flexion (ie, for 6 weeks), but their relative superior effectiveness faded afterward. Histology showed that adhesions were less severe and healing was better in the CS-pHEMA membranes at 3 and 6 weeks. If further studies determine precise amounts or thicknesses of CS coats that will maximize its healing properties, CS-pHEMA should prove useful in clinical settings in which restoration of tendon sheath integrity with a minimum of adhesions is not possible.