Extensor Carpi Ulnaris Tendinopathy in Athletes: A Review of the Conservative and Rehabilitative Options

BACKGROUND

Extensor carpi ulnaris (ECU) tendinopathy is characterized by pain along the dorsal and ulnar aspect of the wrist and distal forearm. It is common in athletes who play stick and racquet sports due to repetitive motion and axial-loading through the wrist and forearm. Conservative therapeutic options include rest, the use of anti-inflammatory medications, and various injections. Rehabilitation via occupational or physical therapy includes therapeutic exercise, splinting, activity modification, manual therapy, and modalities.

METHODS

A narrative review of the literature on ECU tendinopathy is presented, and a case study approach is used to highlight the clinical management of this condition in an elite athlete.

RESULTS

An approach of medical management and rehabilitation allowed this patient to successfully return to play.

CONCLUSIONS

A combination of conservative measures and rehabilitation can be used to treat ECU tendinopathy and permit patients to be symptom-free and return to their desired activities.

Developmental Anatomy of the Radial Bow in Pediatric Patients using 3D Imaging

BACKGROUND

While radial bow shape is well characterized in adults, its development in children is not well understood. Previous studies on the radial bow use radiographs, thus, rotational positioning of the forearm could alter bowing measurements. This study used 3D imaging to better assess the pediatric radial bow.

METHODS

Computed tomography scans from the New Mexico Decedent Image Database were obtained for ages 2 to 16 (females) and 18 (males) (n=152). 3D models were generated using Slicer and Rhino software. Length of the entire radial bow (bicipital tuberosity to sigmoid notch), maximum radial bow, location of the maximum radial bow (bicipital tuberosity to the point of maximum bowing), and distal, middle, and proximal third radial bows were measured.

RESULTS

The length of the entire bow increased with age, with a strong correlation with age (r=0.90, P<0.01). The maximum bow increased with age, with a strong correlation with age (r=0.78, P<0.01). The maximum bow normalized to the length of the entire bow increased mildly with age, mean 0.059 ± 0.012 (r=0.24, P=0.0024), but seems to plateau around age 8. The location of the maximum bow increased with age (r=0.85, P<0.01). The normalized location of the maximum bow remained constant between ages, with a mean of 0.41 ± 0.10 (r=0.12, P=0.14). The normalized distal third bow mildly increased with age (r=0.34, P<0.01), the normalized middle third bow mildly increased with age (r=0.25, P<0.01), and the normalized proximal third bow remained constant between ages (r=0.096, P=0.24).

CONCLUSIONS

Normalized values for maximum, distal third, and middle third radial bow increase with age, while normalized values for location and proximal third radial bow remain relatively constant, suggesting the proportional shape of the radius changes during development, although qualitatively plateaus after age 8.

LEVEL OF EVIDENCE

Retrospective comparative study, Level-III.

Pediatric Phalanx Fractures

Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.

Transphyseal Fracture of the Distal Humerus

Transphyseal fractures of the distal humerus often occur in children younger than 4 years as a result of birth trauma, nonaccidental trauma, or falls from a low height. It is important to identify and treat these injuries in a timely manner to ensure successful management. Most transphyseal fractures of the distal humerus are treated with closed reduction and percutaneous pinning with the aid of an elbow arthrogram. The most common complication following a fracture is cubitus varus caused by growth arrest, malunion, or osteonecrosis of the medial condyle. Normal carrying angles may be restored through corrective lateral closing wedge osteotomy.

Canal Fill of the Forearm Bones When Placing Intramedullary Nails in the Pediatric and Adolescent Populations

BACKGROUND

In the lower extremity, studies have suggested an optimal nail diameter to medullary canal diameter (ND/MCD) ratio to minimize postoperative complications. The goal of this study was to determine whether a correlation exists between the occurrence of complications, angulation, and range of motion and the ratio of the ND/MCD in the upper extremity.

METHODS

A total of 85 radius and ulna fractures treated with flexible intramedullary nails had ND/MCD ratios measured. Random-effects models were developed to determine the association between complications and ND/MCD ratio, angulation and ND/MCD ratio, and range of motion and ND/MCD ratio. The results were reported for unadjusted models and adjusted models.

RESULTS

Of the 85 forearm fractures treated with intramedullary nailing, there were 3 complications. The average follow-up was 6 months. The ND/MCD ratios were categorized as <0.50, 0.50 to 0.59, and ≥0.60. There was not a significant association between the different ratios and angulation, or risk of complication. There was an association between the ND/MCD ratio ≥0.60 and decreased pronation of -1.58° (-2.77° to -0.38°) and supination of -2.68° (-4.91° to -0.46°) (P < .05).

CONCLUSION

This study found that there was not an association between the nail to canal diameter ratio and postoperative angulation in forearm fractures treated with flexible intramedullary nails. When choosing a flexible nail for forearm fractures, there does not appear to be an optimal ratio; it is therefore reasonable to use the ND that passes more easily.

The Mental Health Implications of Obstetric Brachial Plexus Injuries (OBPI) on Parents

BACKGROUND

Obstetric brachial plexus injuries (OBPI) can have mental health implications on parents coping with this injury to their newborn. The purpose of this study was to assess the mental health of mothers with newborns with an OBPI and identify resources that can help screen and treat mental health needs.

MATERIAL AND METHODS

Three groups of mothers were prospectively given a self-reported survey: 1) Newborns with OBPI; 2) Newborns in the nursery without OBPI; 3) Newborns in the neonatal intensive care unit (NICU). The survey consisted of demographic questions, the PHQ-9 and PCL-S screening tools, and parents' exposure to community violence, family support and use of drugs or alcohol.

RESULTS

Fifty-seven mothers were prospectively enrolled, and 30% (17/57) of mothers screened in for post-traumatic stress disorder (PTSD). OBPI mothers had significantly higher rates of PTSD symptoms when compared to mothers of children in the full-term nursery (difference = 36.4%; p < 0.01). No statistically significant difference was found between groups regarding depression symptoms.

CONCLUSIONS

OBPI can be very difficult to cope with for parents and family members. Forty-two percent of mothers with newborns with OBPI or children in the NICU screened in for PTSD symptoms. OBPI clinics should be staffed similarly to the NICU with clinical social workers to appropriately screen and treat parents with PTSD and depression symptoms.

Radiographic Scapholunate Interval in the Pediatric Population Decreases in Size as Age Increases

BACKGROUND

Widening of the scapholunate (SL) interval greater than 2 mm is diagnostic of an injury in adults; however, this absolute number cannot be used for skeletally immature individuals due to the ossification of the carpal bones. The purpose of this study was to determine age-appropriate normative values for the radiographic SL interval in the skeletally immature population.

METHODS

Normal pediatric wrist radiographs were identified. The radiographic SL interval was measured as the distance between the scaphoid and the lunate at the mid-joint space between the scaphoid and the lunate, and the SL and capitolunate angles were measured on lateral views. An initial inter-rater reliability assessment was completed with strong inter-rater reliability.

RESULTS

In all, 529 radiographic series of children (276 male), aged 4 to 17 years, were reviewed. A negative linear correlation between chronological age and distance at the mid-joint space was observed. The average values for the radiographic SL interval ranged from 9.07 to 1.57 mm. The average SL and capitolunate angles were 52.0° and 10.6°, respectively. No linear relationship was found between chronological age and SL or capitolunate angle (R = 0.07 and 0.03, respectively).

CONCLUSIONS

The visible radiographic distance between the scaphoid and the lunate decreases with increasing age as the carpal bones ossify. The normative values defined in this study can be used to determine whether a true widening of the SL interval is present in the pediatric population. No linear relationship exists between chronological age and SL or capitolunate angle.

Human T-cell lymphotrophic virus type-I tax gene induces secretion of human macrophage inflammatory protein-1alpha

Human T-cell lymphotropic virus I (HTLV-I) encodes for a 40-kDa protein, Tax, which is important for the immortalization of T cells. Tax has been shown to transactivate several cellular genes. In this study, we show that MIP-1alpha is selectively expressed and secreted in the tax transfected Jurkat cell line upon mitogen stimulation. Expression of MIP-1alpha-R mRNA in these cells suggests an autocrine role for this chemokine in HTLV-I infected T-cells. Induced MIP-1alpha expression and secretion in PMA/PHA stimulated tax transfected cells correlate with the noninduction of MNP-1 transcription factor, which is intimately involved in downmodulating the MIP-1alpha gene.