Both scanning plane and observer affect measurements of scaphoid deformity

PURPOSE

The influence of angular deformity of the scaphoid on wrist function and arthrosis is debated and the reliability of the described quantitative measurements of deformity has been questioned. We hypothesized that the inherent imprecision with which computed tomography scanning planes are selected introduces another source of variability in measurements of scaphoid deformity, further diminishing their reliability.

METHODS

Sagittal plane images of 15 computed tomograms of normal scaphoids were evaluated in 3 different reconstruction planes. Four observers measured the lateral intrascaphoid angle, the dorsal cortical angle, and the height-to-length ratio of the 45 images in random order and then measured them again in a distinct random order 2 weeks later. The variability of each observer's measurements (intraobserver reliability) was evaluated with Pearson correlation coefficients. The agreement of the measurements made by the 4 observers (interobserver reliability) and the agreement of the measurements of the same bone in different reconstruction planes (interplane reliability) were evaluated using interclass correlation coefficients.

RESULTS

The intraobserver reliability was poor for 27 of 36 comparisons. The interobserver reliability of the dorsal cortical angle and the intrascaphoid angle was poor for all reconstruction planes. The interobserver reliability of the height-to-length ratio was good for 2 planes and poor for the third plane. The interplane reliability was poor for 7 of 12 comparisons, with no single measurement technique remaining consistent for all observers across reconstruction planes.

CONCLUSIONS

Quantitative measurements of scaphoid deformity have very limited reliability for individual observers, between different observers, and depending on the plane in which the image of the scaphoid is produced. Even the most reliable measure of deformity (height-to-length ratio) was not consistent between reconstruction planes. Unless more reliable scanning and measurement techniques are developed ideas about the effect of scaphoid deformity on wrist function will remain to a large degree speculative.

Corrective osteotomy for intra-articular malunion of the distal part of the radius

BACKGROUND

Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most strongly associated with arthrosis and diminished function after such fractures. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the potential for additional injury, osteonecrosis, and nonunion.

METHODS

Twenty-three skeletally mature patients were evaluated at an average of thirty-eight months after corrective osteotomy for an intra-articular malunion of the distal part of the radius. The indication for the osteotomy included dorsal or volar subluxation of the radiocarpal joint in fourteen patients and articular incongruity of > or =2 mm as measured on a posteroanterior radiograph in seventeen patients. Six patients had combined intra-articular and extra-articular malunion. The average interval from the injury to the osteotomy was six months. The average maximum step-off or gap of the articular surface prior to the operation was 4 mm.

RESULTS

One patient had a subsequent partial wrist arthrodesis because of radiocarpal arthrosis, and three patients had additional surgery because of dysfunction of the distal radioulnar joint. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final articular incongruity averaged 0.4 mm, and the final grip strength averaged 85% of that on the contralateral side. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley, and 43% according to a modification of the rating system of Green and O'Brien.

CONCLUSIONS

The results of corrective osteotomy for the treatment of intra-articular malunion are comparable with those of osteotomy for the treatment of extra-articular malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.

Hinged elbow external fixation for severe elbow contracture

BACKGROUND

When it was first introduced, it was hoped that hinged external fixation with a built-in gear mechanism for applying passive motion and static progressive stretch by turning a dial would improve the arc of ulnohumeral motion, by gradually stretching contracted muscles, after open release of a severe elbow contracture.

METHODS

Forty-two patients were evaluated at an average of thirty-nine months after operative release of a severe posttraumatic elbow contracture (defined as < or =40 degrees of motion). Twenty-three patients had been treated, during the early part of the study, with a hinged external fixator that incorporated a worm gear to apply static progressive stretch postoperatively. These patients were compared with nineteen patients who had been treated without hinged external fixation during the later part of the study, when the hinge was used less frequently. The operative techniques did not otherwise change during the study period. Demographic and injury characteristics as well as associated problems were comparable between the two groups.

RESULTS

The average gain in the range of motion after the index procedure was 89 degrees in the patients treated with a hinge and 78 degrees in those treated without a hinge, an insignificant difference with the numbers available (p = 0.175). Complications associated with use of the hinge included five pin-track infections, one case of pin-track osteomyelitis, one ulnar fracture through a pin site, two broken Schanz screws, and two cases of irritation of the ulnar nerve.

CONCLUSIONS

Open release of a severe elbow contracture results in a substantial gain in motion, with or without hinged elbow fixation. The slightly greater improvement in motion provided by the hinge does not justify the associated increase in risk, expense, and complications.

Der Compass-Gelenkfixateur bei akuter und chronischer Instabilität des Ellenbogens

OBJECTIVE

To maintain concentric reduction of an unstable elbow and to allow active exercises after the treatment of complex elbow injuries or their sequelae.

INDICATIONS

Recurrent dislocation or subluxation of the elbow after repair or reconstruction of bony, capsuloligamentous, and/or musculotendinous stabilizers. Tenuous fixation of large coronoid fractures due to fragmentation or osteopenia. Stabilization of the joint after fascial arthroplasty or debridement for infection, if the debridement destabilizes the elbow. Relative indication: maintenance of range of motion after release of contractures.

CONTRAINDICATIONS

Absent patient compliance. Lack of familiarity of surgeon with elbow anatomy and function as well as with hinged external fixation techniques.

SURGICAL TECHNIQUE

Preferably posterior longitudinal midline incision. Placement of axis pin in the center of rotation of the distal humerus. Application of the fixator over this wire. Placement of Schanz screws into humerus und ulna taking care to protect the radial and ulnar nerves. Removal of axis pin. Rechecking of entire frame and tightening.

RESULTS

The authors' experience with the Compass Hinge Fixator documents restoration of stability and excellent motion after relocation of a chronic simple elbow dislocation, a useful role in reconstructing acute and chronic elbow instability after fracture-dislocation, and a limited role in restoring mobility after severe contracture release.

Extra-articular osteotomy for malunited unicondylar fractures of the proximal phalanx

PURPOSE

To evaluate an extra-articular osteotomy rather than an intra-articular osteotomy in the treatment of malunited unicondylar fractures of the proximal phalanx.

METHODS

An extra-articular osteotomy was used to correct the deformity resulting from a malunion of a unicondylar fracture of the proximal phalanx in 5 patients. A closing wedge osteotomy that was stabilized with tension band fixation accomplished realignment of the joint. Each patient was evaluated at a minimum of 1 year after surgery for radiographic healing, correction of angulation, digital motion, postoperative complications, current level of pain with motion, and overall satisfaction with the procedure.

RESULTS

All of the osteotomies healed by 10 to 12 weeks after surgery with an average angular correction from 25 degrees to 1 degrees . The average proximal interphalangeal joint motion improved to 86 degrees from the preoperative average of 40 degrees , whereas the average total digital motion improved from 154 degrees before surgery to 204 degrees at follow-up evaluation.

CONCLUSIONS

This method of extra-articular osteotomy for malunited unicondylar fractures of the proximal phalanx is highly reproducible, avoids the risks of intra-articular surgery, and leads to a predictable outcome.

Treatment of osteoporotic distal radius fractures

Fracture of distal radius is most commonly an injury of the fit osteoporotic patient. As the population and health of older individuals continue to expand, osteoporotic distal radius fractures will become increasingly common. While many older patients have limited functional demands and can accept some deformity and wrist dysfunction, others remain very active into older age and desire optimal wrist alignment and function. The difficulty obtaining reliable fixation in osteoporotic bone presents a challenge to the surgeon that has been partially addressed by newer implants with screws that directly engage the plate, creating fixed angle bolts that have better fixation in osteoporotic bone. Decision-making is based upon a balance of the goals of the individual patient with the risks of intervention.

Psychological factors associated with idiopathic arm pain

BACKGROUND

Psychological and personality factors may be as important as, or more important than, pathological processes in the experience of pain, particularly in patients whose pain has a vague or uncertain source.

METHODS

Validated measures of psychological factors were used to prospectively evaluate fifty-six patients with a single, discrete pain complaint and fifty-one patients with vague, diffuse idiopathic arm pain. Pain was assessed with use of 10-point Likert scales, the Pain Anxiety Symptoms Scale, the Pain Catastrophizing Scale, the Wahler Physical Symptom Inventory, the Body Consciousness Questionnaire, and the Multidimensional Health Locus of Control Scale.

RESULTS

Patients with idiopathic arm pain reported more severe pain at rest (p = 0.02) and with repeated movements (p = 0.01); exhibited higher levels of cognitive anxiety (p = 0.008); demonstrated greater helplessness (p = 0.002), pain magnification (p = 0.007), and overall catastrophic coping mechanisms for dealing with pain (p = 0.005); and showed a tendency for increased somatic complaining (p = 0.07). A multiple logistic regression model identified the total score on the Pain Catastrophizing Scale as the sole predictor of idiopathic pain complaints.

CONCLUSIONS

Pain complaints without a clear physical cause are common and are frustrating for both patients and physicians. Awareness of the psychological factors associated with idiopathic arm pain may lead to more effective interventions designed to improve coping mechanisms while at the same time limiting the use of meddlesome and potentially harmful diagnoses and treatments.

Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting

BACKGROUND

With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts.

METHODS

Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients.

RESULTS

The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121 degrees in the forearm, 131 degrees at the elbow, and 137 degrees at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion).

CONCLUSIONS

When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.

Effective treatment of fracture-dislocations of the olecranon requires a stable trochlear notch

Our goal with this study was to better define and characterize fracture-dislocations of the olecranon and to provide additional data regarding complications and elbow function after operative treatment. Twenty-six patients with fracture-dislocations of the elbow were reviewed retrospectively. Ten had anterior and 16 had posterior fracture-dislocations. Five of 10 patients with anterior injuries and all of the patients with posterior injuries had an associated fracture of the coronoid process of the ulna. One of 10 patients with anterior and 13 of 16 patients with posterior injuries had fracture of the radial head. Only one patient had a true dislocation of the ulnohumeral joint. In the other 25 patients the articular surfaces remained apposed. All 26 patients were treated operatively and followed up for at least 3 years (average, 6 years). The results were good or excellent in 21 of 26 patients according to the system of Broberg and Morrey. The five unsatisfactory results were related to inadequate fixation of the coronoid with subsequent arthrosis (three patients), proximal radioulnar synostosis (three patients), and a subsequent fracture of the distal humerus (one patient). Fracture-dislocations of the olecranon occur in anterior and posterior patterns with specific injury characteristics and pitfalls. The key to effective treatment is stable restoration of the trochlear notch.

Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius

BACKGROUND

The purpose of the present study is to report on a cohort of patients with a volar shearing fracture of the distal end of the radius in whom the unique anatomy of the distal cortical rim of the radius led to failure of support of a volar ulnar lunate facet fracture fragment.

METHODS

Seven patients with a volar shearing fracture of the distal part of the radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation were evaluated at an average of twenty-four months after surgery. One fracture was classified as B3.2 and six were classified as B3.3 according to the AO comprehensive classification system. All seven fractures initially were deemed to have an adequate reduction and internal fixation. Four patients required repeat open reduction and internal fixation, and one underwent a radiocarpal arthrodesis. At the time of the final follow-up, all patients were assessed with regard to their self-reported level of functioning and with use of Sarmiento's modification of the system of Gartland and Werley.

RESULTS

At a mean of two years after the injury, six patients had returned to their previous level of function. The result was considered to be excellent for one patient, good for four, and fair for two. The average wrist extension was 48 degrees, or 75% of that of the uninjured extremity. The average wrist flexion was 37 degrees, or 64% of that of the uninjured extremity. The one patient who underwent radiocarpal arthrodesis had achievement of a solid union. The four patients who underwent repeat internal fixation had maintenance of reduction of the lunate facet fragment. The two patients who declined additional operative intervention had persistent dislocation of the carpus with the volar lunate facet fragment.

CONCLUSIONS

The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The unique anatomy of this region may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively. It is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly.

The treatment of an osteochondral shearing fracture-dislocation of the head of the proximal phalanx: a case report

We report the morphology and treatment of a proximal interphalangeal joint dislocation resulting in an injury to the articular surface of the proximal phalanx and avulsion of the radial collateral ligament from its proximal origin. A large osteochondral fragment was sheared from the radial articular surface of the proximal phalanx and remained displaced volarly after reduction of the joint. Plain radiographs and 2- and 3-dimensional computed tomography images were used to evaluate this unusual injury before surgery. Open reduction and internal fixation using a small K-wire and figure-of-eight wire technique restored the articular surface of the head of the proximal phalanx and gave a satisfactory functional result.

Locking compression plates for osteoporotic nonunions of the diaphyseal humerus

Poor bone quality increases the technical difficulty and complications of operative treatment of nonunions and delayed unions of the diaphyseal humerus in older patients. Plates with screws that lock to the plate (transforming each screw into a fixed blade) are intended to improve the fixation of poor quality bone. Twenty-four patients (20 women, four men) with an average age of 72 years (range, 52-86 years) were followed up for a minimum of 12 months after locking compression plate fixation of an osteopenic delayed union (nine patients) or nonunion (15 patients) of the diaphyseal humerus. Twelve patients had iliac crest cancellous bone grafts, two patients had local graft, and 13 patients had demineralized bone applied to the fracture site. All the fractures eventually healed; two healed after a second procedure for autogenous bone grafting in patients who initially received demineralized bone. Using a modification of the Constant and Murley shoulder score, the results were good or excellent in 22 patients, and fair in two patients. Locking compression plates provide stable fixation of poor quality bone in patients with delayed union or nonunion of the humerus. Successful union and restoration of function are achieved in most patients. We no longer consider osteoporosis a contraindication to operative fixation of an ununited fracture of the humeral diaphysis.

Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus

Although olecranon osteotomy provides excellent exposure of the distal humerus, enthusiasm for this approach has been limited by reports suggesting numerous complications. It has been suggested that specific techniques for creating and repairing an olecranon osteotomy may help limit complications. This paper describes a technique for olecranon osteotomy using an apex, distal, chevron-shaped osteotomy, Kirschner wires directed out the anterior ulnar cortex distal to the coronoid process and bent 180degrees and impacted into the olecranon proximally, and two 22- gauge, figure-of-eight, stainless steel tension wires. A single surgeon used this technique for exposure of a fracture (16 patients) or nonunion (29 patients) of the distal humerus in 45 consecutive patients. One patient returned to activity too soon, had loosening of the wire fixation, and required a second operation for plate fixation of the ulna. The remaining 44 osteotomies (98%) healed with good alignment within 6 months. There were no broken or migrated wires prior to healing. Twelve patients (27%) had removal of the wires used to repair the olecranon: in 6 patients, this was for symptoms related to the wires (13%); 1 for septic olecranon bursitis, and 5 at the time of another procedure (elbow capsular release in 4 patients and submuscular ulnar nerve transposition in 1). Olecranon osteotomy can be used for exposure of the distal humerus with a low rate of complications when specific techniques are used.

Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius

BACKGROUND

Fractures of the distal part of the radius that are associated with complex comminution of both the articular surface and the metaphysis (subgroup C3.2 according to the Comprehensive Classification of Fractures) are a challenge for surgeons using standard operative techniques.

METHODS

Twenty-five patients with subgroup-C3.2 fractures that had been treated with combined dorsal and volar plate fixation were evaluated at an average of twenty-six months after the injury. Subsequent procedures included implant removal in twenty-one patients and reconstruction of a ruptured tendon in two patients.

RESULTS

An average of 54 degrees of extension, 51 degrees of flexion, 79 degrees of pronation, and 74 degrees of supination were achieved. The grip strength in the involved limb was an average of 78% of that in the contralateral limb. The average radiographic measurements were 2 degrees of dorsal angulation, 21 degrees of ulnar inclination, 0.8 mm of positive ulnar variance, and 0.7 mm of articular incongruity. Seven patients had radiographic signs of arthrosis during the follow-up period. A good or excellent functional result was achieved for twenty-four patients (96%) according to the rating system of Gartland and Werley and for ten patients (40%) according to the more stringent modified system of Green and O'Brien.

CONCLUSIONS

Combined dorsal and volar plate fixation of the distal part of the radius can achieve a stable, mobile wrist in patients with very complex fractures. The results are limited by the severity of the injury and may deteriorate with longer follow-up. A second operation for implant removal is common, and there is a small risk of tendon-related complications.

Loss of alignment after surgical treatment of posterior Monteggia fractures: salvage with dorsal contoured plating

PURPOSE

To review the results of internal fixation with a dorsal contoured plate in patients with malalignment after internal fixation of a posterior Monteggia fracture.

METHODS

Seventeen patients with malalignment after surgical treatment of a posterior Monteggia fracture were treated with realignment of the ulna and fixation with a contoured dorsal plate. Fifteen patients had loose fixation and 12 patients had subluxation or dislocation of the ulnohumeral joint. Sixteen patients had fracture of the radial head and 9 patients had fracture of the coronoid process. Nine patients had ancillary procedures on the radial head, 4 had ancillary procedures on the coronoid, 5 had hinged external fixation, and one had fascial arthroplasty. Seven patients had another surgery before the final evaluation related to a complication in 6 patients and a to subsequent injury in 1 patient.

RESULTS

At the final evaluation at an average of 59 months the fracture was healed and the ulnohumeral joint was reduced concentrically in all 17 patients. The average arc of elbow flexion was 108 degrees and the average arc of forearm rotation was 134 degrees. The average American Shoulder and Elbow Surgeons Elbow Evaluation Score was 88. According to the system of Broberg and Morrey, the final result was rated excellent for 5 patients, good for 9, fair for 2, and poor for 1. One patient had fascial arthroplasty as part of the index procedure and 9 patients had radiographic signs of ulnohumeral arthrosis.

CONCLUSIONS

Malalignment after surgical treatment of posterior Monteggia fractures often is associated with unstable fixation. Dorsal contoured plating of the ulna in combination with other procedures can help salvage a malaligned posterior Monteggia fracture with satisfactory function restored in the majority of patients.

Idiopathic arm pain

BACKGROUND

Arm pain with little or no objective abnormality (referred to herein as idiopathic arm pain) is a common and frustrating problem for both patients and physicians. We investigated the relative effect of idiopathic arm pain and arm pain due to a discrete diagnosis on upper-extremity-specific health status.

METHODS

The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was completed by 3888 patients seen over a twelve-month period. Scores for the entire sample, for 496 patients diagnosed with idiopathic arm pain, and for 1379 patients diagnosed with one of twenty-one discrete conditions were compared.

RESULTS

Patients with idiopathic pain reported substantial and highly variable upper-limb-specific dysfunction (average DASH score [and standard deviation], 36 +/- 24 points). Patients with discrete diagnoses also exhibited substantial variation (average standard deviation, 25; range, 6 to 27) as well as long right tails indicating floor effects, particularly for less severe conditions (Pearson correlation of r = -0.87 between the mean DASH score and skewness). Analysis of variance confirmed the ability of the DASH instrument to discriminate among groups of diagnoses of varying severity, but post hoc Tukey analysis identified ten subgroups with substantial overlap of the DASH scores.

CONCLUSIONS

Patients with idiopathic arm pain report substantial and highly variable upper-extremity dysfunction. The wide variations observed in the DASH scores of the patients with idiopathic pain and those with discrete diagnoses are greater than would be expected on the basis of the variations in the objective pathological conditions and may reflect the strong influence of psychological and sociological factors on health status measures.

Volar Barton's fractures with concomitant dorsal fracture in older patients

PURPOSE

To describe a variant of Barton's volar articular shearing fracture of the distal radial articular surface with a subtle concomitant fracture of the dorsal metaphyseal cortex.

METHODS

This fracture pattern was observed in 6 women and 2 men with an average age of 67 years (range, 58-76 years). All 8 patients were treated with a volar plate and screws. The dorsal metaphyseal fracture was not recognized in 5 patients and a volar buttress plating technique using an intentionally undercontoured volar plate was used. In 3 patients the dorsal fracture line was identified before surgery and the plate was contoured to fit the volar surface of the distal radius.

RESULTS

All 5 patients treated with an undercontoured plate had loss of the normal palmar tilt of the distal radius (average,-9.4 degrees; range, 0 degrees to-22 degrees ) and dorsal translation of the distal radial articular fragments. For the entire group the palmar tilt averaged-5.9 degrees (range, 0.0 degrees to-22.0 degrees ), the ulnar inclination 19 degrees (range, 10 degrees -23 degrees ), and the ulnar variance-0.9 mm (range, 0.0 to-3.0 mm). All patients attained forearm supination of 80 degrees and the average pronation was 75 degrees (range, 45 degrees -80 degrees ). According to Sarmiento's modification of the system of Gartland and Werley there were 1 excellent, 6 good, and 1 fair results. The average Patient-Rated Wrist Evaluation score was 16 (range, 0-35).

CONCLUSIONS

Some fractures with an oblique volar marginal articular fracture of the distal radius and volar radiocarpal subluxation (known as Barton's fracture) may also have a fracture through the dorsal metaphyseal cortex. Failure to identify this fracture line can lead to dorsal translation and angulation of the distal radius articular surface, particularly when an undercontoured volar plate is used for internal fixation.

Surgical treatment of persistent dislocation or subluxation of the ulnohumeral joint after fracture-dislocation of the elbow

PURPOSE

To review the results of surgical reconstruction of posttraumatic elbow instability in the setting of either intact or repaired olecranon process using a protocol incorporating hinged elbow fixation.

METHODS

Thirteen consecutive patients with ulnohumeral instability after a fracture-dislocation of the elbow, adequate articular surfaces, and adequate, stable alignment of the olecranon were treated with temporary hinged external fixation, preservation, or reconstruction of both the coronoid process and radiocapitellar contact and with repair or reconstruction of the lateral collateral ligament complex. There were 9 men and 4 women with an average age of 45 years. Seven patients had a terrible triad pattern injury and 6 had a posterior Monteggia pattern injury. All 13 patients had fracture of the radial head and 10 patients had fracture of the coronoid process.

RESULTS

At an average follow-up period of 57 months stability was restored in every patient. The average Disabilities of the Arm, Shoulder, and Hand questionnaire score was 15 and the average Mayo score was 84, with 6 excellent, 4 good, and 3 fair results. The average arc of ulnohumeral motion was 99 degrees. Six patients had radiographic signs of arthrosis including 5 of 6 patients with olecranon fracture-dislocations.

CONCLUSIONS

A stable, functional elbow can be restored in most patients with persistent instability after fracture-dislocation of the elbow using a treatment protocol incorporating hinged external fixation.

Wrist joint ganglion presenting as a painless mass in the palm: report of 2 cases

Ganglions occur commonly in the wrist and arise from the radiocarpal and intercarpal joints. Although ganglions present commonly as masses on the dorsal or volar surface of the wrist, ganglions from wrist joints appear rarely at other locations in the hand. We report 2 cases of ganglions arising from wrist joints that presented as painless masses in the center of the palm without signs or symptoms of median or ulnar nerve compression. Surgical treatment required extensile exposure to trace the proximal stalks to their joints of origin. Knowledge of the possibility that a painless mass in the palm could be a ganglion arising from a joint in the wrist allows proper presurgical planning and informed consent.

Excision of heterotopic bone around the elbow

Heterotopic ossification about the elbow is common and sometimes contributes to a disabling loss of motion. The traditional trepidation and pessimism regarding surgical excision of heterotopic bone is giving way to a realization that operative treatment is successful in most cases and dramatic functional improvements can be obtained. Familiarity with extensile exposure and operative technique will increase the safety and efficacy of the procedure.

Operative release of ankylosis of the elbow due to heterotopic ossification. Surgical technique

BACKGROUND

Although uncommon, complete ankylosis of the elbow secondary to heterotopic ossification results in severe disability. The results of surgical management remain unclear.

METHODS

A single surgeon used a consistent operative technique to treat complete osseous ankylosis of the elbow in eleven limbs in seven patients after severe burns and in nine elbows in eight patients after trauma. The elbows in the burn cohort were more often ankylosed in extension (average, 47 degrees of flexion) compared with those in the trauma cohort (66 degrees of flexion), and they had more skin problems (three elbows required a free microvascular muscle transfer for coverage) and associated problems of the shoulder, wrist, and hand.

RESULTS

Four patients in the burn cohort and three patients in the trauma cohort failed to regain at least 80 degrees of ulnohumeral motion. After a repeat release in three burn patients and three trauma patients, and at an average follow-up of forty months, the average arc of ulnohumeral motion was 81 degrees in the burn cohort and 94 degrees in the trauma cohort. Six of the eleven limbs in the burn cohort and five of the nine in the trauma cohort had a good result. The average score according to the American Shoulder and Elbow Surgeons elbow assessment form was 72 points for the burn cohort and 76 points for the trauma cohort.

CONCLUSIONS

Osseous ankylosis of the elbow is a severely disabling problem, and attempts to regain mobility are both worthwhile and safe. The results are comparable when the ankylosis is caused by burns or trauma despite the greater complexity of osseous ankylosis in the burned arm. Patients and surgeons should be aware of the small risk of recurrent heterotopic ossification and the moderate risk of pain or recurrent contracture after operative release.

Posttraumatic radial club hand

Fifteen adult patients with an unstable ununited fracture of the distal third of the radius and severe radial deviation deformity resembling a radial club hand were retrospectively reviewed at an average of 25 months after operative treatment. There were eight women and seven men with an average age of 57 years (range, 33-79 years). The average duration of nonunion was 56 months (range, 6-252 months). Six patients had a concomitant fracture of the ulna and four had dislocation of the distal radioulnar joint. Three patients were treated with wrist arthrodesis and 12 with plate fixation and autogenous bone grafting. The distal ulna was excised and used for bone graft in eight patients. Correction of deformity was facilitated by z-lengthening of the brachioradialis and flexor carpal radialis in four patients and distraction histogenesis (llizarov) in two patients. One patient failed to heal the fracture and was treated with wrist arthrodesis. Functional alignment and use of the hand was restored in all patients.

Radial nerve palsy associated with high-energy humeral shaft fractures

PURPOSE

To determine whether the radial nerve should be explored when there is a complete sensory and motor deficit after a high-energy fracture of the humeral diaphysis.

METHODS

Twenty-four patients aged 16 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. Eleven fractures were open-6 of these were part of a very complex upper-extremity injury (multiple ipsilateral fractures in 3 patients and near amputation in 3). All 11 patients with open fractures and 3 of 13 patients with closed injuries had radial nerve exploration.

RESULTS

All 6 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. Five of 6 had primary repair of the radial nerve, and none recovered. All 8 intact explored nerves and 9 of 10 unexplored nerves recovered; the only nonrecovery occurred in a patient treated with closed intramedullary rod fixation who may have had iatrogenic nerve injury. The average time to initial signs of recovery was 7 weeks (range, 1-25 weeks). The average time to full recovery was 6 months (range, 1-21 months).

CONCLUSIONS

Transection of the radial nerve is usually associated with open fractures of the humerus that are part of a very complex upper-extremity injury. The results of primary nerve repair in this circumstance are poor, likely related to an extensive zone of injury and the need for nerve grafting. Intact nerves and nerve palsies that are part of a closed fracture nearly always recover, even after high-energy injuries. Because the first signs of nerve recovery and complete recovery of the nerve can be quite delayed, patience is merited before considering tendon transfers.

Current concepts in the treatment of distal radial fractures

Surgical indications for the treatment of distal radial fractures are evolving. It is important to identify the various articular fragments and their significance to facilitate optimal surgical treatment of these fragments from the standpoint of both internal and external fixation. New techniques in the visualization and stabilization of the articular surface and the treatment of defects in the metaphysis, including the use of cement to buttress the articular surface, have been brought to the forefront. A treatment algorithm for associated injuries to the distal radioulnar joint is also helpful.