Heat generation during ulnar osteotomy with microsagittal saw blades

Ulnar shortening osteotomy is a surgical treatment option for patients with symptomatic ulnar positive variance for a variety of reasons. Delayed healing and nonunion of the osteotomized sites have been reported and present problematic complications of this procedure. Studies have shown nonunion rate with transverse cuts ranging from 8-15%. The goal is to achieve parallel cuts, thus maximizing the contacting bony surface area for a better union rate. The senior surgeon attempted using a custom thick blade to insure parallel cuts. The concern is whether the heat generated during such a cut would contribute to non-union. It is our hypothesis that complications with ulnar shortening osteotomy using a thick blade are secondary to excess heat generation. When generated heat surpasses the threshold temperature of bone tissue, the organic matrix is irreversibly damaged and necrosis of the bony ends may occur. The present study measured the heat generation during ulnar osteotomy using different blade thicknesses. Thirty-five fresh turkey femurs, having similar size and cortical thickness of the human ulna, were used. Loading was done at three different speeds of 0.66, 1.0, and 1.5 mm/second corresponding respectively to 30, 20, and 10 seconds for the complete cut. A general linear statistical model was fitted relating temperature rise to three predictive factors: blade thickness, sensor distance, and initial bone temperature. There was a statistically significant relationship between temperature rise and all three predictor variables at the 99% confidence level. There was no statistically significant relationship between temperature rise and the number of cuts with the same blade up to 10 times. Compared with the single microsagital saw blade, the temperature rise for the double thickness blade was 14% higher and for the triple thickness blade was 23% higher. The temperature rise was inversely related to the speed of the cut. The temperature rise for the bone cut in 30 seconds was 1.5 times higher than the temperature rise when the bone was cut in 10 seconds. Complications with ulnar shortening osteotomy may be secondary to excess heat generation. A new thick saw blade design and the use of proper internal/external irrigation may overcome the problem.

Etiology of Dupuytren's disease

The etiology of Dupuytren's disease is still unknown in spite of significant recent advances in identifying the type of cell responsible for initiating the process. Associated factors such as alcoholism, smoking, work, diabetes, and epilepsy are discussed. The course of the disease in men as compared with women is also discussed. Recent evidence has shown that there may be genetic and immunologic factors involved. Superoxide free radicals and their effect on fibroblast proliferation may play a significant role in the disease process.

Kienbock's disease: treatment by implantation of vascular pedicle and bone grafting

Eleven patients with stage II and IIIA Kienbock's disease treated with vascular pedicle implantation and bone grafting were reviewed to determine the long term efficacy of the procedure. Eight wrists had a negative ulnar variance and three wrists had a neutral ulnar variance. The procedure involved implanting the second dorsal metacarpal artery and its venae commitantes into a hole made in the lunate through a dorsal approach. Cancellous bone graft from the dorsal aspect of the distal radius was loosely packed in the hole to secure the pedicle. Follow-up was from 37 to 140 months with an average of six years. Nine patients had significant long term pain relief, improved function, and required no additional procedures. In two patients, continued pain necessitated proximal row carpectomy at two and 4.5 years postoperatively. Ten of the eleven patients had no worsening of their radiographic staging, but in no patient was the architecture of the lunate restored. There were no complications. The results are promising enough to recommend consideration of this procedure in the early stages of Kienbock's disease in patients with a neutral or negative ulnar variance.

Wrist arthrodesis. Technique and functional evaluation

Wrist arthrodesis is a reliable procedure that, although it sacrifices motion for stability, provides the patient with relief from pain. This review of 26 wrist arthrodeses performed in 24 patients using the AO technique, with plate and screw fixation and iliac crest bone graft, shows a 100% union rate and high patient satisfaction. Using a questionnaire, the patients revealed that they adapted to their fused wrists but still had difficulty with some activities, such as getting the hand into tight places, heavy lifting, and positioning the hand for some specific activities. The most common complication was fracture at the ends of the plate. Removal of the plate after solid healing of the fusion is recommended strongly.

Late presentation of triceps rupture. A case report and review of the literature

Rupture of the triceps tendon is a rare injury. The treatment protocol for acute injuries is well described and predictably successful. However, if the diagnosis is missed, the surgeon is presented with a more difficult management problem. We report the case of a 19-year-old woman who presented 8 months following a triceps tendon rupture. The diagnosis and technique for repair and postoperative rehabilitation are described. A review of the literature is also presented. Although our patient regained excellent motion and function, we feel the injury is best managed by avoiding misdiagnosis via a high index of suspicion and a careful examination at the time of injury.

Staple leg profile influence on pullout strength: a biomechanical study

Bone staples have widespread applicability in orthopaedic surgery. Their use, however, is limited by inconsistent quality of fixation. Prior studies have shown potential for improvement in the reliability of staple fixation through a change in the design of the staple legs. To identify a superior leg cross section profile, pullout strength of 5 different newly designed staple leg cross sections were evaluated in fresh frozen human cadaveric bones before and after toggle loading. The tests were repeated in a synthetic bone model with variable but consistent densities. The curvilinear square profile had the highest pullout strength in both the cadaveric and synthetic bone, followed in descending order by square, circular, and triangular profiles. Controlling for density, the pullout strength of the curvilinear square profile was 8% higher than the square profile and 34% higher than the circular profile. The triangular profiles had the least resistance to pullout force before and after cyclic loading. The curvilinear square may be the best profile for the cross section of the staple leg for maximum pullout strength and may expand the clinical use of staples in bone fixation.

Internal fixation of oblique metacarpal fractures. A biomechanical evaluation by impact loading

Internal fixation of oblique metacarpal fractures was studied in a cadaver model by impact loading. One hundred twenty fresh-frozen human metacarpals underwent compressive and bending impacts after oblique osteotomy and internal fixation. Dorsal plating with lag screws, 2 dorsal lag screws (2-screws), crossed Kirschner wire tension band (crossed K-wire), 5 stacked intramedullary Kirschner wire (5-rod), and paired intramedullary Kirschner wire (2-rod) were used. The failure occurred within 6 msec in the compressive impact and was almost immediate in the bending impact. The dorsal plate and the intramedullary rod fixations were the strongest and were not significantly different from the intact specimens in compressive impact; they were, however, 19% weaker in bending impact. The 2-screws was the weakest fixation in this group. This fixation was 59% weaker in compressive impact and 47% weaker in bending impact compared with the dorsal plating.

Heterotopic ossification

Heterotopic ossification is a well-recognized condition frequently encountered by the orthopedic surgeon. Although typically asymptomatic, heterotopic ossification can be a complication of extreme severity. This article is a review of literature and attempts to clarify the definition, and delineates the etiology, incidence, risk factors, and current modes of prophylaxis and treatment of various types of heterotopic ossification.

Vascular injuries associated with elbow fractures and dislocations

The association between elbow fractures and dislocations and vascular injury was reviewed at our institution over a ten year period from 1983 to 1993. A total of fifty-six cases of acute elbow fracture or dislocation which required operative treatment were reviewed and of these two had a concomitant vascular injury. In both these cases diagnostic imaging studies confirmed the clinical diagnosis and arterial reconstruction was done. These cases are reviewed along with the arterial anatomy about the elbow which allows for significant collateral circulation. The general principles of fracture or dislocation reduction followed by vascular reassessment and arterial reconstruction if needed are reviewed.

Mechanics of retrograde nail versus plate fixation for supracondylar femur fractures

Two common types of internal fixations for the supracondylar femur fractures--the retrograde intramedullary nail and the 95 degrees sideplate and screw--were mechanically tested in synthetic composite femur bones to determine the quantitative differences in their inherent rigidity. The medial and lateral femoral condyles were separated by a sagittal osteotomy, and a standardized medial segmental shaft defect was created at the distal shaft. The osteotomized specimens were stabilized using one of the two implants and were tested in different modes of loading. The bending stiffness of both constructs were not significantly different in varus compression, medial bending (pure varus), and bending in flexion. The plate and screw implant was three times stiffer in lateral bending (pure valgus) and 1.2 times stiffer in valgus compression than the retrograde supracondylar nail (p < 0.01). The torsional stiffness of the plate and screw implant was significantly higher, 1.6 times that of the nail. Clinically, the most important and common cause of implant failure is varus loadings due to loss of medial cortical contact. Although the retrograde nail was less rigid in other physiologically less critical modes of loading, it had a rigidity comparable to that of the plate in varus loading. Therefore, a supracondylar nail may be considered a mechanically possible alternative to plate fixation.

Acute gamekeeper's thumb. Quantitative outcome of surgical repair

Ten consecutive patients with 11 complete ulnar collateral ligament tears who had early surgical repair were evaluated at an average of 42 months' followup. The mean arc of motion at the metacarpophalangeal joint at 50.9 degrees was less than the 73.7 degrees seen in the uninjured thumbs. At the interphalangeal joint, the mean arc of motion in the injured thumb was 101.6 degrees compared with 112.6 degrees on the uninjured side. Ulnar laxity was decreased slightly compared with the contralateral thumb (14.0 degrees versus 15.3 degrees) and radial laxity was 10.3 degrees on both sides. The mean grip strength and key pinch were similar between the injured and uninjured sides: grip strength was 32.3 kg in the injured thumbs and 34.0 kg in the uninjured; key pinch was 8.1 kg in the injured thumbs and 8.8 kg in the uninjured. Good stability with slight decrease in motion was obtained in our patients.

Anomalous hand muscle found in the Guyon's canal at exploration for ulnar artery thrombosis. A case report

A diagnosis of ulnar artery thrombosis should be considered when a patient reports symptoms of ulnar neuropathy, ischemia in the hand, or a mass in the hypothenar area. A history of repetitive blunt trauma to the hypothenar area is particularly suggestive of this. Ulnar artery thrombosis is possibly associated with an anomalous muscle in the Guyon's canal. The anomalous muscle in this case originated on the flexor carpi ulnaris muscle, was ulnarly innervated, and joined the flexor digiti minimi muscle distally. This patient had a history of blunt injury and a significant smoking history, thus, a causal relationship between the anomalous muscle and ulnar artery thrombosis cannot be stated with certainty.

Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity

The mangled extremity severity score (MESS) is a scoring system that can be applied to mangled extremities and help one determine which mangled limbs will eventually come to amputation. The MESS is a graduated grading system based on skeletal and soft tissue injury, shock, ischemia, and age. The records of 37 patients having sustained 43 open fractures or mangled upper extremity injuries, seen and treated at the University of New Mexico's Regional Trauma Center between April 1987 and September 1990, have been reviewed. All nine extremity injuries with a MESS of greater than or equal to seven were amputated, and 34 of 34 with a MESS of less than seven were salvaged. Nine Grade IIIC and six mangled extremities were identified in our study. Five of these Grade IIIC and four of the mangled extremities with a MESS of greater than or equal to seven were amputated. All Grade IIIC or mangled extremities with a MESS of less than seven were salvaged. In conclusion, the MESS is an early and accurate predictor for identifying the extremities that may be best treated by amputation.

The reduction clamp: a simple device for closed reduction during intramedullary nailing

Reduction of femoral shaft fractures prior to passing the guide pin during intramedullary fixation may be a challenging problem, especially in delayed reductions or obese patients. We describe a simple and useful instrument for obtaining and maintaining reduction for closed intramedullary fixation. It provides a three-point fixation that may be locked into position to maintain the reduction. The surgeon is not required to hold the device in position while passing the guide pin, the reamer, or the nail. It frees the surgeon's hands, minimizes the need for an assistant, and reduces harmful x-ray exposure to the hands.

Hemodynamic comparison of microsurgical repairs for large arterial defects

Twenty-eight femoral arteries in 14 rats were used to compare transverse closures and end-to-end anastomoses in blood vessels approximately 1 mm in diameter. The transverse closures were applied to arteriectomies created by excising one-half the circumference of the vessel over a length of 1 mm. The end-to-end anastomoses were performed after resecting a 1-mm segment. Recordings were made of pre- and postrepair flow velocity and three-point diameter measurements every 5 minutes using a 20-MHz pulsed Doppler velocimeter and digimatic caliper. Maximum reductions in flow velocity were 18% and 31% for the transverse repair and end-to-end anastomosis, respectively. Otherwise, intergroup comparisons of the postrepair normalization of both flow velocity and vessel diameter showed few significant differences (P < 0.05). We conclude that arterial defects involving no more than half the diameter of the vessel can be effectively repaired in significantly less time using the transverse closure.

Isokinetic dynamometric technique for spasticity assessment

This study was conducted to determine the feasibility of quantifying spasticity by measuring the resistance to passive movement using an isokinetic dynamometer. A quantifiable method was developed by determining the summation of the four consecutive resisting torque amplitudes during flexion and extension of the knee at specified speeds and range of motion. A more rigorous assessment was made by finding the slope of the linear regression curve of torque-velocity data. Although the values of maximum torque were higher in the spastic group than in the normal group, the difference was statistically significant only when the sum of the torque amplitudes was considered (P < 0.0028). Values of the maximum torque as well as the sum of the torque amplitudes increased in a linear fashion (r > 0.75) with increasing velocity. The slopes of the torque-velocity curves were greater in spastic subjects than in normal subjects. The sensitivity to the rate of stretch was statistically greater (P < 0.0004) for the spastic group than normals only when the sum of torque amplitudes was considered. The corresponding data obtained during the flexion and extension of the knee were not statistically different (P > 0.05). Serial summation of torque amplitudes and measurement of slope in the torque-velocity curve are sensitive and repeatable methodologies for the measurement of spasticity assessment.

Comparative fatigue strengths and stabilities of metacarpal internal fixation techniques

To study quantitative differences in the fatigue strength and stability obtained with 5 types of internal fixation of metacarpal fractures, 105 preserved human metacarpals were cyclically tested in bending, torsion, and axial loading after oblique osteotomies of the metacarpal and internal fixation. The dorsal plate with lag screw was superior in all modes, followed by the two dorsal lag screws, crossed Kirschner wire tension banding, and intramedullary Kirschner wire fixation. The five intramedullary and the paired intramedullary Kirschner wire fixations were not statistically different. The fatigue life of the plate fixation was significantly larger in bending (1.5 times), torsion (1.6 times), and axial loading (2.5 times) than the second strongest fixation, two dorsal lag screws. Its initial rigidity was significantly higher in axial loading (1.5 times) but was not statistically different in bending and torsion.

Ulnar translation of the carpus in rheumatoid arthritis: an analysis of five determination methods

Five x-ray methods of assessing ulnar translation of the carpus were compared to each other. Overall, we found the uncompensated semiquantitative method proposed by Gilula et al. to be the most practical and the best method with a sensitivity index of 82%, a specificity index of 88%, an accuracy of 87%, and an interobserver correlation of 90%. The method, however, decreased in specificity and accuracy when a corrective formula was applied to adjust the ulnometacarpal angle to zero degrees deviation. Our conclusion is that the sensitivity indices are relatively low for all methods, and underdiagnosis may occur. At present the semiquantitated method of Gilula et al. is the most practical, with the highest sensitivity index, and is recommended as a screening tool for assessment of ulnar translation of the carpus.

Hemodynamic comparison of microsurgical closures for longitudinal arteriotomies

Twenty-four femoral arteries in 12 rats were used to compare longitudinal and transverse closures in blood vessels approximately 1 mm in diameter. The closure techniques were applied to a simple longitudinal slit, 1 mm long, and to a longitudinal defect, 0.5 mm wide and 1 mm long. Comparisons were made of the change in pre- and postrepair flow velocities, recorded every 5 min using a 20-MHz pulsed Doppler velocimeter. Maximum reductions in flow velocity (linearly related to volume flow) were 10% and 29% for the longitudinal and transverse repairs, respectively, when applied to the longitudinal slit, and 65% and 19%, respectively, when applied to the larger arteriotomy. An analysis of variance indicates that the differences in the normalization of flow velocities during the immediate postrepair period are significant (P < 0.05). We conclude that optimal flow normalization is achieved by applying the longitudinal repair to the simple slit and the transverse repair to the larger arteriotomy.

Ulnar nerve compression at the wrist. Ulnar tunnel syndrome

Compression neuropathy of the ulnar nerve at the wrist can be caused by several lesions. The most common cause is a carpal ganglion followed by occupational repeated trauma to the hypothenar area. This process is in contrast to carpal tunnel syndrome in which the majority of the cases are idiopathic in nature with no local cause found except for synovitis of the flexor tendons. The site of the lesion will determine the clinical picture whether it is both motor and sensory abnormalities, only motor paralysis or only sensory abnormality. The latter is rare. If the abnormality is purely motor, then the compression is distal in the ulnar tunnel and the hypothenar muscles are usually spared. Carpal ganglia must be sought and removed. After an extensive search through the literature, I found only one report in which thickening of the volar carpal ligament was found to be the cause of ulnar nerve compression. I encourage the use of the term "ulnar tunnel syndrome" to discuss these lesions and the classification outlined by Shea to determine the site of the lesion. Patients with type 2 syndrome usually present late because of the lack of sensory changes. Average delay in obtaining a diagnosis of 5 months was found in my patients. The condition should be suspected if spontaneous clumsiness or awkwardness of the use of the hand occurs in a middle-aged patient.

Evolution of bone inhomogeneity around a hole in an orthotropic plate of bone: theoretical predictions

The problem of the evolution of bone inhomogeneity around a hole in a plate of bone with orthotropic symmetry is considered. The internal remodeling theory of Cowin and Hegedus is employed to show the existence of final inhomogeneity following stress concentration. The speed of remodeling around the hole and its variation with respect to distance is investigated. Results indicate that the effect of stress concentration around a hole is slightly less pronounced if bone is considered orthotropic rather than transversely isotropic. The speed of remodeling is found to be unaffected but the amplitude of inhomogeneity with respect to distance drops and disappears slightly faster if bone is considered orthotropic.

New Mexico rattlesnake bites: demographic review and guidelines for treatment

The demographic features, treatment, and outcome of 36 rattlesnake envenomation cases are reviewed. Two populations at special risk are identified: (1) young children (12/36) who sustain lower extremity bites, and (2) adults who consume alcohol and handle snakes (10/36) who sustain upper extremity bites. Antivenin was used in 22 cases with only one serious case of serum sickness. Three definite diagnoses of compartment syndrome were made on the basis of elevated compartment pressures. Hand bites accounted for 20 of the 36 cases. The greatest functional disability followed digit bites in that 11 patients developed decreased motion and sensation. The indications for fasciotomy and debridement are discussed, both for digit and non-digit envenomations. General treatment recommendations are given.

Management of greater arc carpal fractures

Greater arc injuries are fracture dislocations that involve the perilunar carpal bones. The commonest of these injuries is the dorsal transscaphoid perilunate fracture dislocation. The recommended treatment for acute injuries is open reduction and Kirschner wire fixation of the scaphoid fracture through a dorsal midline approach. Stability to the midcarpal joint is thus provided and no further pins are needed. Established scaphoid nonunions are treated by bone grafting and Herbert screw fixation through a volar approach. Scaphocapitate fracture syndrome is treated by open reduction and pin fixation of the displaced capitate fragment through the dorsal approach. If the scaphoid is displaced it is also openly reduced and pinned.

The effect of prolonged blood stasis on a microarterial repair

There is much controversy in the literature about the effect of blood stasis on the patency rate following microvascular repair. Sixty Sprague Dawley rats underwent transection and repair of their femoral arteries. The rats were divided into three groups, which had their repaired arteries clamped for 1 1/2, 2, and 2 1/2 hours. Patency was evaluated by the "stripping test," and the presence of a "flicker" both immediately and on the second day of the experiment. At the time of evaluation on the second day, all arteries in Group I were patent, in Group II two were thrombosed and in Group III, five out of 20 thrombosed. The only significant statistical difference was found between Groups I and III in both immediate (p less than 0.0025) and second day (p less than 0.05) evaluations. Results indicate that the "safe limit" for blood stasis in a repaired artery of 0.8 mm diameter is 1 1/2 hours.

Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption

Five patients between 10 and 46 years old were reviewed after a latissimus dorsi muscle transfer to restore elbow flexion. Loss of elbow flexion resulted from traumatic brachial plexus paralysis in all five patients. All had some weakness in other muscle groups in the upper extremity. The follow-up period was from 25 to 68 months (average = 39.4 months). A range of motion of 0 degrees/115 degrees, 10 degrees/100 degrees, 0 degrees/110 degrees, 0 degrees/70 degrees was obtained. After the transfer, three patients could supinate the forearm, and supination of 90 degrees, 15 degrees, and 10 degrees was measured. Two patients could lift 4 lb, while two others could lift 1 and 1.5 lb, respectively. Evaluation of activities of daily living by a standardized test revealed disappointing results. The two patients with less than 90 degrees elbow flexion had initial paralysis of the latissimus dorsi muscle at the time of injury. This procedure should not be done unless the latissimus dorsi muscle is normal.

Salvage of replanted parts of the upper extremity

Twelve patients with fifteen replanted parts had vascular exploration in order to salvage the replantation after impending failure developed. Arterial occlusion only was found in eleven parts, while arterial and venous occlusion was found in the other four. Vein grafts were used in ten parts, with success in eight. Thrombectomy was done in six, with success in only one. It was possible to salvage nine of the fifteen replanted parts. The best results were obtained when the revision was done within eleven hours after the replantation.

Radiocarpal dislocation--classification and rationale for management

Radiocarpal dislocation is a rare injury. The authors reviewed seven cases with this injury and identified two groups of patients. Type I involves a dislocation of only the radiocarpal joint, while Type II involves intercarpal dislocation also. Four patients were included in Type I dislocation (3 dorsal and 1 volar). The other three patients had Type II dislocations, all of which were volar dislocations. Two patients had evidence of injury to the median and ulnar nerves at the time of the injury and both recovered completely. Closed reduction was possible with good results in three patients with Type I dislocation. All patients with Type II dislocation required open reduction and all had residual problems. The distinction between Type I and Type II is essential in order to evaluate the full extent of the injury. Closed reduction should always be attempted in Type I dislocation. Type II dislocation should be treated by open reduction and repair of all torn ligaments.

Transscaphoid perilunate fracture-dislocation. Result of open reduction and pin fixation

Sixteen patients with 17 transscaphoid perilunate fracture-dislocations were treated by open reduction and pin fixation. Open reduction was performed through a volar approach in only one wrist, a dorsal approach in nine wrists, and combined volar and dorsal approaches in seven wrists. Primary bone grafting was performed in four patients. The follow-up period was from five months to eleven years and two months, with an average of 2.69 years. Seven patients had median nerve injury and all recovered. Of the 17 wrists, the scaphoid fracture healed in 15. This injury should be treated by early open reduction through a dorsal incision and pinning of the scaphoid fragments in an anatomic position. Avascular necrosis of the proximal fragment is not an indication for further surgery as long as the fracture is well reduced with evidence of healing. This replacement of necrotic bone by new bone requires several years. Primary bone grafting is unnecessary.

Carpal tunnel syndrome in hemophilia

Carpal tunnel syndrome occurring as a complication of hemophilia is documented in the literature. Most reports, however, indicate that the condition can be relieved by splinting and replacement therapy. Two cases of carpal tunnel syndrome in hemophiliacs are presented. In one patient, replacement therapy was successful in relieving the condition. However, in the other patient, decompression of the carpal tunnel and internal neurolysis of the median nerve were carried out after replacement therapy failed. To our knowledge, this is the first time that intraneural bleeding in the nerve has been documented as a cause of peripheral neuropathy in hemophilia. Surgical release of the carpal canal together with the epineurectomy and internal neurolysis resulted in complete recovery.

Brachial artery disruption following closed posterior elbow dislocation in a child--assessment with intravenous digital angiography. A case report with review of the literature

An 11-year-old boy sustained complete brachial artery disruption following closed posterior elbow dislocation. This is the first documentation in the English-language literature of this type of arterial transection following closed elbow dislocation in a child. It is also the first report of surgical repair of the brachial artery following elbow dislocation in a child. The patient's radial pulse was absent the day following the injury, and on Doppler examination blood flow was audible over the radial artery. Hand perfusion, however, remained excellent. Intravenous digital angiography demonstrated complete disruption of the brachial artery. This procedure is relatively painless compared with conventional angiography with percutaneous arterial puncture. The procedure provides the treating physician with an objective method for assessing brachial artery integrity. Arterial repair may decrease the potential risks of delayed complications, e.g., cold intolerance, potential growth disturbance, and possible delayed neurovascular residues associated with localized ischemia to the forearm and hand.

Volar dislocation of the metacarpophalangeal joint. Pathologic anatomy and report of two cases

Of two cases of volar metacarpophalangeal joint dislocation, the thumb was affected in one. This is the first case of its kind reported in the English-language literature. Patients with this injury are older than patients with the more common dorsal dislocation. The mechanism of injury seems to be direct trauma to the dorsum of the hand with the metacarpophalangeal joint acutely flexed. The pathologic anatomy may be a combination of a dorsal capsular tear, a tear of one or both collateral ligaments, and a tear of the volar plate with interposition in the joint. Attempt at closed reduction, even if a pin is used percutaneously to transfix the joint, almost invariably will lead to recurrence of the deformity. The recommended treatment for such very rare injuries is open reduction through dorsal, or both dorsal and volar, approaches; removal of the incarcerated volar plate from the joint; and repair of all torn ligaments.

Wrist arthrography in acute carpal injuries

A prospective study of 10 patients with acute complex carpal dislocations was undertaken. Preoperative wrist arthrograms were done in these patients. We then observed the ligamentous tear through both volar and dorsal approaches at the time of open reduction. Perilunate dislocation was always an integral part of the pathology in all patients, except in one patient with radiocarpal dislocation. Communication between the radiocarpal and midcarpal joint was found in all patients, except in one patient with radiocarpal fracture-dislocation. Volar extrusion of the contrast material occurred in all patients except one. Dorsal extrusion occurred only in three patients. The arthrography findings correlated well with the pathology at surgery, as far as indicating the level of the ligamentous disruption. Volar tears were much more common than dorsal tears.

Coracoid fracture as a complication of surgical treatment by coracoclavicular tape fixation. A case report

In a 22-year-old man surgically treated for acromioclavicular dislocation, coracoid fracture was caused by bone failure at the Mersaline loop. The addition of bony erosion between the two drill holes in the clavicle caused the tape to loosen and the deformity to recur. Postoperative infection may also have played a role in causing the coracoid fracture. When tape is used, it should be passed around the clavicle, not through it. If the deformity recurs, coracoid fracture should be suspected.

Interfascicular nerve grafting

Interfascicular nerve grafting is a useful method to repair nerves with gaps. Good motor recovery can be obtained, and return of some degree of sensibility is possible. The procedure can be used to overcome small gaps that result from neglected sharp lacerations or after failure of primary repair, or large gaps that result from loss of nerve substance or traction lesions. Primary nerve repair should be done for acute lacerations. However, in old lacerations (more than three weeks old) and in nerve gaps of more than 2 cm in length, a functional recovery can still be expected after nerve grafting. The recovery of intrinsic function in median and ulnar nerve lesions above the elbow was poor. The intrinsic recovery in these patients will be reported when long-term follow-up results are available. Recovery of intrinsic function in median nerve grafts at the wrist level was much better than for lesions of the ulnar nerve at the same level. This may be related to the anatomy of the ulnar nerve in this area. By separating the dorsal cutaneous branch from the main trunk of the nerve, using it as a donor graft, better results are to be expected.