Treatment of swan neck deformity in cerebral palsy.

Swan neck deformity in patients with cerebral palsy can result from hand intrinsic muscle spasticity or overpull of the digital extensors. After accurate identification of the etiology of the deformity, surgical treatment is directed at correcting the underlying muscle imbalance. Intrinsic lengthening can be used to treat intrinsic muscle spasticity, whereas central slip tenotomy is employed when digital extensor overpull is the deforming force. Accurate diagnosis and application of the proper surgical technique are essential when treating swan neck deformity in patients with cerebral palsy.

Comparison of in vitro motion and stability between techniques for index metacarpophalangeal joint radial collateral ligament reconstruction.

PURPOSE: To evaluate a technique using interference screws to secure a tendon graft for reconstruction of the radial collateral ligament (RCL) of the index finger metacarpophalangeal (MCP) joint. We hypothesized that this technique would provide equivalent stability and flexion as a 4-tunnel reconstruction. METHODS: We isolated the RCL in 17 cadaveric index fingers. A cyclic load was applied to the intact RCL across the MCP joint to assess flexion, ulnar deviation at neutral (UD 0), and ulnar deviation at 90° of MCP joint flexion (UD 90). The RCL was excised from its bony origin and insertion. We performed each reconstruction (4-tunnel and interference screw) sequentially on each specimen in a randomized order using a palmaris longus tendon graft. We repeated testing after each reconstruction and compared differences from the intact state between techniques using paired t-tests for all joint positions (flexion/UD 0/UD 90). RESULTS: There was no statistically significant difference in UD 0 or UD 90 between the intact state and after interference screw reconstruction. Compared with the intact state, there was significantly less UD 0 and significantly more UD 90 after 4-tunnel reconstruction. There was no statistically significant difference between techniques when we compared changes in -UD 0 or UD 90. Change in flexion was statistically significantly different, which indicates that the interference screw technique better replicated intact MCP joint flexion compared with the 4-tunnel technique. CONCLUSIONS: Interference screw reconstruction of the index RCL provides stability comparable to 4-tunnel reconstruction and is less technically challenging. These results substantiate our clinical experience that the interference screw technique provides an optimal combination of stability and flexion at the index MCP joint. CLINICAL RELEVANCE: Using an interference screw to reconstruct the index RCL is less challenging than 4-tunnel reconstruction and provides stability and range of motion that closely resemble the native MCP joint.

Anatomy of the radial collateral ligament of the index metacarpophalangeal joint.

PURPOSE: To describe the origin and insertion of the radial collateral ligament (RCL) of the index metacarpophalangeal (MP) joint, relative to the MP joint line and other landmarks readily discernible intraoperatively. METHODS: We dissected 17 fresh-frozen human cadaveric index fingers. We removed all overlying soft tissue from the MP joint except for the proper RCL. We dissected the RCL from its original insertion under loupe magnification while concurrently marking the ligamentous origin and insertion points. We measured distances of these points in relation to the bony landmarks (dorsal, articular, and volar surfaces) using digital photo analysis. The same observer recorded all measurements to reduce systematic error. RESULTS: The center of the metacarpal attachment of the RCL was located 5.4 ± 1.1 mm from the dorsal border of the metacarpal, 8.0 ± 2.2mm from the volar border of the metacarpal, and 10.3 ± 3.2mm from the articular surface of the MP joint. The total width and height of the metacarpal origin site were 5.8 ± 1.6 and 6.4 ± 1.4 mm, respectively. The center of the proximal phalanx attachment of the RCL was located 6.8 ± 1.4 mm from the dorsal border of the proximal phalanx, 5.7 ± 0.9 mm from the volar border of the proximal phalanx, and 4.4 ± 0.8mm from the articular surface of the MP joint. The total width and height of the phalangeal origin site were 5.0 ± 1.1 and 5.7 ± 0.9 mm, respectively. CONCLUSIONS: Our study defines the anatomic origin and insertion of the RCL of the index MP joint in relation to landmarks that are identifiable during surgery. CLINICAL RELEVANCE: We believe this information will be useful to surgeons when repairing or reconstructing the RCL, allowing for recreation of normal RCL anatomy.

Mechanics of an anatomical reconstruction for the thumb metacarpophalangeal collateral ligaments.

PURPOSE: This study biomechanically evaluated a technically easy variation of anatomical reconstruction of the thumb metacarpophalangeal (MCP) joint ulnar (UCL) and radial (RCL) collateral ligaments. Based on previous work describing the anatomical origin and insertion of these ligaments, we hypothesized that, using these attachment points, joint stability would be restored without significant loss of MCP flexion. METHODS: The collateral ligaments were isolated in 30 cadaveric thumbs (15 UCLs and 15 RCLs). A cyclical load was applied to the MCP joint to assess flexion, radial/ulnar deviation in neutral, and radial/ulnar deviation in 30° of flexion. The collateral ligaments were detached from the bone while their origin and insertion points were marked. Using these sites, anatomical ligament reconstruction was performed with a palmaris longus tendon graft and interference screw fixation. Cyclical testing was repeated on the reconstructed ligaments. RESULTS: No significant difference was found between intact and reconstructed UCLs when tested for radial deviation in neutral, radial deviation in 30° of flexion, or total MCP flexion. No significant difference was found between intact and reconstructed RCLs when tested for ulnar deviation in neutral, ulnar deviation in 30° of flexion, or total MCP flexion. CONCLUSIONS: Our anatomical reconstruction is simple and restores UCL and RCL anatomy as compared with current techniques in the literature by placing the origin and insertion at their anatomical points with use of an interference screw. Using these anatomical origins and insertions, we were able to restore the MCP flexion and stability seen in an intact ligament. CLINICAL RELEVANCE: Our anatomical reconstruction offers a technically easy option for reconstruction of thumb MCP collateral ligament injuries, restoring joint stability without sacrificing flexion.

Long-term results following surgical treatment of elbow deformity in patients with cerebral palsy.

PURPOSE: To evaluate the long-term results of surgical intervention for elbow flexion deformity in cerebral palsy. We hypothesized that improvements in elbow extension and flexion posture angle at ambulation would be maintained over time with preservation of active flexion. METHODS: A total of 23 patients (23 elbows) were available for long-term follow-up. Patients had fixed elbow contractures less than 45° and were treated with partial elbow muscle lengthening. Active and passive range of motion and elbow flexion posture during ambulation were measured at each follow-up, and longitudinal results were compared. RESULTS: Active extension and flexion posture angle during ambulation improved 12° and 63°, respectively, with an 8° loss of active flexion. CONCLUSIONS: Soft tissue lengthening of the anterior elbow can provide statistically significant lasting improvements in active extension and flexion posture during ambulation in patients with cerebral palsy. Our long-term findings substantiate previously reported short-term results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Anatomy of the thumb metacarpophalangeal ulnar and radial collateral ligaments.

PURPOSE: To describe the origin and insertion of the ulnar (UCL) and radial collateral ligaments (RCL) of the thumb metacarpophalangeal (MCP) joint. METHODS: We dissected 18 UCLs and 18 RCLs from fresh-frozen human cadaveric thumbs. We removed all soft tissue overlying the MCP joint, isolating the proper collateral ligaments. We detached the collateral ligaments from the bone while marking their origin and insertion points and measured these attachment sites in relation to bony landmarks by digital photo analysis. RESULTS: The center of the UCL origin at the metacarpal was 4.2 mm from the dorsal surface and 5.3 mm from the articular surface. The dorsal aspect of the metacarpal origin site was 2.1 mm from the dorsal edge of the metacarpal. The center of the phalangeal insertion was 2.8 mm from the volar surface and 3.4 mm from the articular surface. The volar aspect of the phalangeal insertion site was 0.7 mm from the volar edge of the phalanx. The center of the RCL origin at the metacarpal was 3.5 mm from the dorsal surface and 3.3 mm from the articular surface. The dorsal aspect of the metacarpal origin site was 1.5 mm from the dorsal edge of the metacarpal. The center of the phalangeal insertion was 2.8 mm from the volar surface and 2.6 mm from the articular surface. The volar aspect of the phalangeal insertion site was 0.5 mm from the volar edge of the phalanx. CONCLUSIONS: Our study accurately defined the origin and insertion sites of the UCL and RCL of the thumb MCP joint. CLINICAL RELEVANCE: An accurate definition of the anatomical origin and insertion points of the thumb MCP UCL and RCL may allow for more successful surgical repair and reconstruction.

Removal of locked volar plates after distal radius fractures.

PURPOSE: We present our experience with removal of locked volar distal radius plates and screws and note the indications for removal, types of plates removed, completeness of hardware removal, and complications occurring during plate removal. METHODS: We reviewed all distal radial volar locking plates removed at our institution from 2004 to 2009. A total of 28 patients operated on by 5 hand surgeons were identified. We gathered information regarding the incidence of successful removal of hardware and operative findings in cases of difficult removal of hardware. RESULTS: A total of 28 patients (16 women, 12 men) underwent removal of locked volar distal radius plates from 2004 to 2009. The mean length of implantation was 63 weeks (range, 3-223 wk). Reasons for removal of hardware included tenosynovitis, tendon rupture, pain, and prominent or intra-articular hardware. Of 28 cases of locked volar plate removal, 2 had complications. In the first case, a screw was cross-threaded in an earlier generation DVR Hand Innovations plate implanted in 2003. The plate and screw were removed by rotating them out as 1 unit. In the second case, in which the current generation DVR Hand Innovations plate was implanted in 2007, the recess in the screw head had been stripped on insertion. The plate was cut and the remaining fragment of plate and screw were removed together. Despite these difficulties, hardware was successfully removed completely in 28 patients. CONCLUSIONS: This case series highlights the result that all removals of locked volar plates were successful. There were 2 complications, and strategies for removal are described. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The effect of altered hand position and motor skills on stereognosis.

PURPOSE: Poor stereognosis has been considered to be indicative of abnormal cerebral sensory function, and therefore a relative contraindication for upper extremity surgery in hemiplegic cerebral palsy. The effect of hand position and motor function on stereognosis has not been studied; decreased hand mobility can decrease a person's ability to recognize objects in the hand and can be an important component of stereognosis. METHODS: Twenty-one normal subjects had their nondominant arm positioned to simulate the hemiplegic hand posture of forearm pronation and wrist and digital flexion. Subjects were asked to identify 12 common objects in 3 successive trials, with the first and third trials in the simulated hemiplegic position and the second trial in normal hand position and motor function. This accounted for a learning effect. RESULTS: Normal subjects had significantly (p < .0001) decreased stereognosis when placed in a simulated hemiplegic hand position with decreased digital and wrist extension, identifying fewer items (means 7.6 and 9.3 in successive trials) in the hemiplegic hand position than in the normal hand position (mean 11.7). CONCLUSIONS: Decreased stereognosis in cerebral palsy patients might be related to altered hand mobility and not solely to central nervous system dysfunction. It should be used cautiously when guiding surgical indication, as it may be surgically correctable.

Return to Play After Forearm and Hand Injuries in the National Basketball Association.

BACKGROUND: Hand injuries can result in significant time away from competition for professional basketball players. Time to return to play after hand injuries in elite athletes has not been well described. PURPOSE: To report the return to play from metacarpal fractures, phalangeal fractures, and thumb ligament tears in National Basketball Association (NBA) players over a 5-year period. STUDY DESIGN: Descriptive epidemiology study. METHODS: The NBA transaction report was analyzed from January 2009 to May 2014. Players were identified if they were added to the inactive list (IL), missed games due to their injury, or underwent surgery as a result of hand injury. Number of games missed due to injury, days spent on the IL, and age at injury were calculated by injury type and location. RESULTS: One hundred thirty-seven injuries were identified: 39 injuries to the hand and 98 injuries to the finger. Three major injury patterns were identified and analyzed: metacarpal fractures (n = 26), phalangeal fractures (n = 33), and thumb ligament tears (n = 9). The type of injury sustained affected return to play (P < .05). All thumb ligament tears required surgery and had the longest return to play of 67.5 ± 17.7 days (P < .05). The return to play for surgically treated metacarpal fractures (56.7 ± 26.3 days) was significantly greater than nonsurgically treated metacarpal fractures (26.3 ± 12.1 days; P < .01). Return to play for surgically repaired phalangeal fractures (46.2 ± 10.8 days) trended greater but was not significantly different than phalangeal fractures treated nonsurgically (33.3 ± 28.5 days; P = .21). CONCLUSION: Hand injuries in professional basketball players can lead to prolonged periods of time away from competition, especially after surgery. This study provides guidelines on expected return to play in the NBA after these common hand injuries.

Diagnosis, Treatment, and Return to Play for Four Common Sports Injuries of the Hand and Wrist.

Hand and wrist injuries in the high-level athlete are challenging because they may be underestimated by the patient, family, and team, and return to play may be longer than desired. The needs of the player and the team must be balanced with the long-term functional ramifications of the injury. Four common soft-tissue sports injuries are flexor digitorum profundus avulsion, flexor pulley rupture, extensor carpi ulnaris dislocation, and thumb metacarpophalangeal joint ulnar collateral ligament injury. For each of these injuries, the assessment, treatment, and considerations for return to play should be individualized on the basis of the patient, the sport, and the timing of the injury.

Opinions regarding the management of hand and wrist injuries in elite athletes.

Injuries to the hand and wrist are commonly encountered in athletes. Decisions regarding the most appropriate treatment, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. Little recognition in the literature exists regarding the need for a different approach when treating these injuries in elite athletes and the timing to return to play. This study explored the complexities of treating hand and wrist injuries in the elite athlete. Thirty-seven consultant hand surgeons for teams in the National Football League, National Basketball Association, and Major League Baseball completed a brief electronic survey about the management of 10 common hand injuries. Notable variability existed in responses for initial management, return to protected play, and return to unprotected play for all injuries, aside from near consensus agreement (94%) that elite athletes with stable proximal interphalangeal dislocations could immediately return to protected play. Basketball surgeons were less likely to recommend early return to protected play than non-basketball surgeons. Baseball surgeons were more likely to recommend early unprotected play after scaphoid fixation. Football surgeons were more likely to recommend earlier return to protected play after thumb ulnar collateral ligament injuries, whereas basketball surgeons were less likely to recommend earlier return to protected play. This study demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The findings emphasize the need to individually tailor treatment decisions to the patient's desires and demands, particularly in high-performance athletes.

Surgical treatment of swan-neck deformity in hemiplegic cerebral palsy.

PURPOSE: Previously described surgical treatments for dynamic swan-neck deformity in cerebral palsy are technically difficult and time consuming. Typically only a few fingers could be addressed at one sitting, and postoperative swelling and stiffness were often incurred. An easy procedure of central slip tenotomy is described that allows for multiple fingers to be addressed, with minimal postoperative morbidity. METHODS: Fifteen patients (33 fingers) with hemiplegic cerebral palsy and dynamic swan-neck deformities of their fingers were treated. Only swan-neck deformities of greater than 20 degrees were considered for treatment. Pre- and postoperative measurements of swan-neck deformity were recorded. A central slip tenotomy was performed through a transverse incision proximal to the proximal interphalangeal joint. The joint was pinned in 10 degrees of flexion for 4 weeks, and then active extension was allowed to 10 degrees short of full extension and blocked with an oval-8 splint. Average patient age was 16 years (range 5-44 years). All patients had concurrent procedures performed on the extremity. Average follow-up evaluation was 23 months (+/-12 months). RESULTS: Improvement in dynamic swan-neck deformity averaged 32 degrees . Preoperative swan-neck deformity averaged 38 degrees and postoperative swan-neck deformity averaged 6 degrees . No swan-neck deformity was worse than its preoperative state, and no patient developed boutonniere deformity. No patient lost active or passive flexion after the procedure. All patients would repeat the procedure. CONCLUSION: Central slip tenotomy is a reliable treatment for dynamic swan-neck deformity in cerebral palsy in patients without dynamic metacarpophalangeal flexion deformity. Because of the simplicity of the procedure, it can easily be added to the treatment of the entire upper extremity in cerebral palsy.