Median nerve palsy presenting as absent elbow flexion: a result of a ruptured pectoralis major to biceps tendon transfer.

We describe a patient with a preexisting posttraumatic brachial plexopathy who had a complete high median nerve palsy due to rupture of the pectoralis major to biceps transfer near its distal insertion at the elbow region.

Myositis ossificans of the hand.

We present a case of myositis ossificans of the hand and review the clinical, radiological, and histological presentation, as well as the appropriate therapeutic management.

Tilted lateral radiographs in the evaluation of intra-articular distal radius fractures.

The anatomy of the distal radius confounds the assessment of fracture displacement of the lunate facet. Since reduction of the articular surface is paramount to obtaining good clinical results, this study was designed to evaluate whether a radiograph taken 22 degrees from true lateral (forearm held at a 22 degrees angle from the horizontal film cassette) would enhance the accuracy of measuring displacement. Fifteen lunate facet fractures of varying depression were produced in 7 fresh cadaveric wrists. Posteroanterior (PA), standard lateral, and 22 degrees tilted lateral radiographs were obtained of each fracture pattern. Four observers reviewed the films and measured the depression of the fragments from their anatomic position. Measurement error from actual depression averaged 1.1 mm when the evaluators evaluated the 22 degrees lateral and PA films, 1.5 mm for the standard lateral and PA views, and 0.8 mm for the standard lateral, 22 degrees lateral, and PA radiographs (combined group). The decrease in measurement error obtained from all 3 groups was statistically significant. The results of this study suggest that the 22 degrees tilted lateral, either in combination with the standard lateral radiograph or just with the PA view, may help the hand surgeon better understand the intra-articular depression of lunate facet fractures of the distal radius.

Pediatric elbow trauma.

This article provides a summary of the acute management of pediatric elbow trauma. Treatment options are reviewed for all pediatric fractures, specific recommendations are outlined, and complications are addressed. Particular emphasis is placed on the common, but often complicated supracondylar fracture of the distal humerus.

Rehabilitation after subcutaneous transposition of the ulnar nerve: immediate versus delayed mobilization.

We studied 36 patients who had clinical signs and symptoms consistent with cubital tunnel syndrome and in whom nonoperative management failed. These patients underwent anterior subcutaneous transposition of the ulnar nerve followed by either immediate (20 patients) or delayed (16 patients) mobilization. All patients were evaluated with an outcomes assessment questionnaire, and 35 of the 36 were given repeat physical examinations. After surgery, there were no significant differences between the two groups in pain relief, weakness, or patient satisfaction (71% of the immediate mobilization group and 74% of the delayed group) were satisfied. Secondary quantitative outcomes such as grip strength, lateral pinch, or two-point discrimination were also not significantly different between the groups. Both groups had a statistically significant improvement in first dorsal interosseous and adductor pollicis muscle strength. In the immediate mobilization group, however, patients returned to work and resumed activities of daily living earlier (median 1 month) than patients in the delayed mobilization group (median 2.75 months). Therefore, we conclude that anterior subcutaneous transposition provides a high degree of satisfaction and relief of symptoms regardless of when mobilization is initiated. However, immediately mobilizing the patient significantly influenced how early the patient returned to work and resumed activities of daily living.

Radial longitudinal deficiency. A review and update.

Treatment of patients with radial longitudinal deficiency remains challenging for the hand surgeon. A thorough knowledge of the anomalous anatomy and the varied presentation is vital to effect a sound treatment plan. This article includes a review of the pertinent historical background, a discussion of current recommendations, and a detailed critical review of recent contributions to the field.

Static external fixation in the hand and carpus.

Static external fixation in the hand and carpus remains a valuable part of the hand surgeon's armamentarium for the treatment of complex injuries. This article describes a brief history, indications, case examples, and complications using these constructs. Pertinent pitfalls are emphasized to avoid suboptimal outcomes.

A comparative mechanical analysis of plate fixation in a proximal phalangeal fracture model.

A biomechanical study compared the mechanical properties of hand and craniofacial plating systems commonly used in proximal phalangeal fractures. Two plates of each of the various systems were mounted dorsally on a yellow-birch-dowel model of a proximal phalanx after a transverse cut was made in the middle of the section of the dowel, modeling a midshaft transverse osteotomy or fracture. Torsional rigidity, as well as four-point bending rigidity in apex dorsal, lateral and volar directions, was achieved. Failure testing in apex palmar four-point bending was then examined. Between plating systems, torsion varied 1,600% and results of apex palmar testing varied 1,500%. Apex palmar moment-to-failure testing varied 1,000% and represented a 3.5%-38% range of intact proximal phalangeal strength. This also represented 12%-128% of the maximum calculated in vivo bending moments of the proximal phalanx. The wide variation in plate strengths and stiffness raises questions as to the suitability of certain plating systems with regard to early mobilization. Moreover, some plating systems tested were mechanically weaker than the reported strengths of certain Kirschner wire fixation techniques.

Basal joint arthritis: trapeziectomy with ligament reconstruction and tendon interposition arthroplasty.

This article provides a qualitative and quantitative outcomes assessment of a consecutive series of 27 patients (30 thumbs) with basal joint arthritis of the thumb undergoing ligament reconstruction and tendon interposition arthroplasty. Outcome analysis revealed that 24 (89%) patients were satisfied with the relief of pain provided by the arthroplasty and 23 (87%) would undergo surgery again. Eighteen (67%) thumbs were noted to have improvement in the ability to perform activities of daily living. Significant improvements were noted in web space measurements and in grip and pinch strength determination. X-ray film assessment using the trapezial space ratio averaged 0.33 +/- 0.08 in preoperative x-ray films of thumbs with stage III and IV degenerative arthritis and 0.23 +/- 0.07 in thumbs following basal joint arthroplasty. This represents a total decrease of 51% in the trapezial space ratio following arthroplasty compared to the normal values obtained in previous studies and 33% compared to the preoperative values obtained in this study. Outcomes assessment at a mean of 42 months after surgery showed that there was no significant correlation between maintenance of trapezial height and both objective and subjective clinical outcomes. Although ligament reconstruction consistently failed to restore trapezial height, primary and secondary clinical outcomes following basal joint arthritis were almost uniformly satisfactory.

Mycoplasma hominis septic arthritis: two case reports and review.

Mycoplasma hominis is normally a commensal of humans. When the organism is pathogenic, it primarily causes disease in the genitourinary tract. Septic arthritis caused by M. hominis is a rare condition that occurs chiefly in the postpartum period, in immunosuppressed hosts, or in patients who have recently undergone urinary tract manipulation. Arthritis caused by M. hominis is clinically indistinguishable from septic arthritis caused by other bacteria. Diagnosis is often delayed because infection with this organism is not suspected or because it grows slowly, if at all, in routine culture media. Appropriate therapy often leads to a good outcome, although relapses and resistance have been reported.

Fractures of the supracondylar process of the humerus.

The supracondylar process of the humerus is a relatively rare but well-known anatomic variant that can be associated with other anomalies. While it usually remains clinically silent, the spur can be responsible for a wide spectrum of symptoms. We present 3 patients with fractures of the supracondylar process and review 12 other cases in the literature. The supracondylar process has potential for fracture and important neurovascular sequelae.

Evaluation of uncemented total hip arthroplasty in patients with avascular necrosis of the femoral head.

Thirty-seven uncemented primary porous coated anatomic (PCA) total hip arthroplasties (THA) that were performed in 33 patients for the diagnosis of avascular necrosis (AVN) between June 1984 and December 1986 were reexamined at four- to six-year follow-up periods. Final clinical evaluation showed an 86-point average Harris hip rating (range, 47-100 points), which had improved from an average preoperative rating of 42 points (range, 20-61 points). Thigh pain, which was usually not functionally limiting, occurred in 11 patients (25%), and seven patients (16%) had a moderate or severe limp. Nine patients (20%) required the use of a cane. Long-term radiographic evaluation in 37 hips demonstrated acetabular cup migration in one hip, acetabular lucencies in four hips (11%), and acetabular bead loosening in ten hips (27%). Femoral subsidence occurred in five hips (14%) and femoral bead loosening in 11 hips (30%). Thirty hips (81%) demonstrated radiographic evidence of stable bony ingrowth. No revisions were performed for aseptic loosening, but two prostheses were removed for infection. These results of uncemented THA in patients with AVN appear to be as good or better than the results reported for cemented arthroplasty in AVN at this interval of a follow-up period. This study supports the use of uncemented devices, especially with the newer designs and increasing surgical experience in this difficult patient population.

Posterior interosseous nerve compression due to an enlarged bicipital bursa confirmed by MRI.

Posterior interosseous nerve compression is a well-described clinical entity with many aetiologies. Fewer than 12 documented cases of the condition due to an enlarged bicipital bursa exist in the literature. We describe a case in which magnetic resonance imaging (MRI) was used in the preoperative assessment of a mass in the proximal forearm with a clinical diagnosis of partial posterior interosseous nerve compression.

Septic polyarthritis and its relation to systemic disease processes. A report of three cases.

In the case of a postoperative joint infection, the orthopaedic surgeon is frequently blamed. Certain intrinsic disease processes, however, make a joint more susceptible to infection. In these three reports of septic polyarthritis, all patients had underlying systemic disorders, including rheumatoid arthritis, diabetes mellitus, and hemophilia A. Two of the three patients had had no recent surgical procedures. This suggests that the development of a pyarthrosis may depend at least as much on the patient's underlying systemic condition as on the surgeon and his or her technique.