Wrist Arthroscopy in Children and Adolescent With Chronic Wrist Pain: Arthroscopic Findings Compared With MRI.

BACKGROUND: Wrist arthroscopy is a dynamic diagnostic procedure and its indications are growing as a treatment modality in the adult population. The aim of the study was to retrospectively report our series of pediatric and adolescence with chronic wrist pain, with or without wrist instability who underwent wrist arthroscopy after failing at least 4 months of conservative management. Our secondary aim was to report the sensitivity and specificity of clinical examination and magnetic resonance imaging evaluation for various injury subgroups against the gold standard of the arthroscopic findings. Technical challenges, complications, and outcomes are also discussed. METHODS: A retrospective review of the medical records of 32 pediatric and adolescent patients who underwent wrist arthroscopy was conducted. Preoperative clinical diagnosis, radiographic, and intraoperative findings including classifications of triangular fibrocartilage complex (TFCC) and interosseous ligaments were obtained. Patients were followed up to 1 year postoperatively and were discharged if symptom free. RESULTS: Thirty-three wrist arthroscopies in 32 patients were performed from 1996 to 2004. There were 2 male and 30 female patients. At arthroscopy 16 wrists were found to have TFCC injuries, 11 wrists had scapholunate injuries, and 8 had lunotriquetral (LT) injuries. Clinical examination for diagnosis of TFCC injury was too sensitive and nonspecific; however, clinical diagnosis of scapholunate injury was sensitive and specific. LT injury was under diagnosed clinically. Magnetic resonance imaging was found to have a low sensitivity for diagnosis of LT injury but diagnosis of TFCC was sensitive and specific. CONCLUSIONS: The sex ratio of 2 males:30 females was startling. Nevertheless, this therapeutic level 3 study supports a thorough search for pathology in any patient with persistent wrist symptoms because pathology was identified in 32 of the 33 wrists at arthroscopy. LEVEL OF EVIDENCE: Level III-Therapeutic.

What does standard rehabilitation practice after total hip replacement in the UK entail? Results of a mixed methods study.

BACKGROUND: There is evidence of prolonged poor function in patients following total hip replacement (THR). Studies of progressive resistance training (PRT) interventions to improve function are often compared to 'standard' practice which is not well defined. This study aimed to investigate 'standard' rehabilitation care in the UK after total hip replacement (THR) as well as determine whether PRT was part of 'standard' care. METHODS: After ethical approval, questionnaire item development about rehabilitation practice was guided by a focus group interview (after informed consent) with physiotherapists (n = 4; >5 years post-qualification) who regularly treated THR patients. An online questionnaire investigating the exercises prescribed and rehabilitation practice following THR was developed and sent to physiotherapists working in hospitals in the UK. The survey was performed from January to May 2011. The survey results were analysed (frequency (%) of responses) focusing on the exercises the physiotherapists considered important, as well as their use of PRT in prescribed regimes. RESULTS: 106 responses were obtained from physiotherapists in the UK. The survey respondents considered that the most important muscles to target in all phases of rehabilitation were the hip abductors (62.2%), followed by the quadriceps (16.9%), and other muscles (21%). Exercise type prescribed revealed no consensus, with weight bearing (42%), functional (45%) and Bed-based/Bridging/Postural exercises (13%) favoured. 83.7% were able to define the basis of progressive resistance training (PRT), but only 33% prescribed it. CONCLUSIONS: Standard physiotherapy rehabilitation in the UK after THR is variable, and appears to rarely include PRT. This may be a factor in prolonged poor function in some patients after this common operation.

Management of neck of femur fracture in an adult with short stature and learning disability.

Neck of femur fractures (NOFF) are one of the major health concerns, with their incidence and the cost of care rising each year. Though a plethora of literature remains available on NOFF and its management, we found very little evidence for management of NOFF in patients with short stature and learning disability. Because of this unique combination of conditions in our patient, we had to deviate from the standard practice in terms of the implant choice. The usage of cemented Asian C stem AMT with a 36 mm metallic head which is normally reserved for total hip replacements, helped us obtain the desired hip joint stability. This was supplemented by early involvement of the learning disability physiotherapy team and eventually the patient had a satisfactory outcome at 8 months of follow-up. This rare amalgamation of NOFF, short stature and learning disability deserves more attention which our case report hopes to achieve.

Pain and outcomes of carpal tunnel release under local anaesthetic with or without a tourniquet: a randomized controlled trial.

We conducted a prospective randomized controlled trial to investigate carpal tunnel decompression under local anaesthesia. Carpal tunnel decompression was performed in 37 wrists using local anaesthesia and an arm tourniquet and 36 without tourniquet but with a local anaesthetic mixture containing adrenaline. Patients who underwent carpal tunnel decompression using a tourniquet experienced a significantly greater degree of pain when compared with those who did not have a tourniquet. Pain and hand function improved to a similar degree in both groups. We conclude that carpal tunnel decompression performed with a tourniquet causes patients unnecessary pain with no additional benefit as compared with the wide-awake carpal tunnel decompression without use of a tourniquet. LEVEL OF EVIDENCE: I.

Missed diagnosis of ankle pseudoaneurysm following ankle arthroscopy: a case report.

BACKGROUND: Pseudoaneurysm formation is rare complication after arthroscopy with incidence of 0.008%, easy to misdiagnose. Its potential catastrophic sequelae should not be underestimated. CASE PRESENTATION: We present a case of missed diagnosis of traumatic anterior tibial artery pseudoaneurysm in a 39 years old female, instead treated as post operative arthroscopy infection. The diagnosis was confirmed with a duplex ultrasound scan and referred to the vascular surgeon with successful out come. CONCLUSION: In view of rare presentation this complication, it is easily missed. According to one study, incidence of anatomic variations of anterior tibial artery range from 2.4 to 12%. Because of this anatomical variation in course along with other factors, pseudoaneurysm formation at ankle is relatively high. In this report, we discuss the diagnosis, anatomical variations of anterior tibial artery and prevention of this complication following arthroscopy. We believe that surgeons operating in this region should take into account these anatomical variations preoperatively.

Guyons canal syndrome due to accessory palmaris longus muscle: aetiological classification: a case report.

INTRODUCTION: Accessory muscles and anatomic variations are well described at the Guyon's canal. Though this case report is similar to variants published in previous reports, it differs from the rest due to rapidity of worsening of symptoms in few months following use of cane. CASE PRESENTATION: We report a case of 69 year old man with ulnar nerve compression at Guyon's canal by accessory palmaris longus arose from distal third palmaris longus and from deep fascia of forearm. The hypertrophied muscular portion of accessory palmaris longus crosses over the ulnar nerve and artery at Guyon's canal becomes tendinous before merging with the hypothenar muscle. CONCLUSION: With co-existing anatomical variants, pressure in Guyon's canal might rapidly increase, might be causative factor and cause compression of deep branch of ulnar nerve following frequent dorsiflexion of wrist like in our case. Following division of accessory palmaris longus symptoms rapidly improved. In this article we discuss the aetiological classification, diagnostic criteria and treatment based on available evidence.