Operative Treatment of Medial Epicondyle Fractures in Pediatric and Adolescent Patients: Comparative Study of Internal Fixation with Kirschner Wires or Cannulated Screws / 대한스포츠의학회지

Purpose@#Medial epicondyle fractures are a common elbow injury in pediatric and adolescent patients. The management of these fractures continues to be debated. This study aims to review the long-term clinical and radiological outcomes of operative treatment of medial epicondyle fractures in pediatric and adolescent patients. @*Methods@#In this study, 24 consecutive patients were categorized into two groups as follows: group 1, 10 patients undergoing internal fixation with Kirschner wires (K-wires) and group 2, 14 patients undergoing internal fixation with cannulated screws. To assess clinical outcomes, Mayo Elbow Performance Score were used in addition visual analogue scale for pain, subjective range of motion, ulnar nerve irritation symptoms, residual instabilities and requirement for secondary surgery were checked. To access the radiological outcomes, check the bone union and possible deformities secondary to the medial epicondyle fractures were examined. @*Results@#There were no cases of immediate or residual ulnar nerve irritation symptoms and no cases of residual deformity or valgus instability. There was no radiological evidence of loss of reduction and all patients had achieved bone union at last follow-up. And all patients had performed secondary surgery for hardware removal regardless of symptomatic hardware irritation. @*Conclusion@#Both K-wires fixation for younger children and screw fixation for near skeletal maturity children may provide favorable clinical and radiological outcomes at long-term follow-up, with low morbidity and radiographic deformity. In the K-wire fixation group, it is thought that preoperative explanation is needed because the K-wires tends to be removed earlier than screw fixation group due to hardware irritation.

Early Corrective Osteoclasis for Malunited Pediatric Medial Condylar Fracture of the Humerus

Fractures of the medial condyle of the distal humerus in children are very rare, and the younger the age, the more difficult it is to diagnose. These fractures include an intra-articular fracture and a Salter–Harris type IV growth plate fracture. Therefore, the prognosis is poor if the fracture is neglected or misdiag-nosed because of the high incidence of complications such as nonunion, angular deformity, or joint contracture. This paper reports a case of a four-year-old child who presented with a malunion of the medial condyle of the humerus with good results after an early corrective osteoclasis.

Refracture after locking compression plate removal in displaced midshaft clavicle fractures after bony union: a retrospective study

Background@#A midshaft clavicle fracture is a common fracture that typically responds well to open reduction and internal fixation (ORIF). However, refracture can occur after implant removal (IR). This study aimed to analyze the rate of refracture and related factors after removal of the locking compression plate (LCP) for displaced midshaft clavicle fractures. @*Methods@#We retrospectively reviewed the medical records of 201 patients who had undergone ORIF with LCP for midshaft clavicle fractures after IR after bony union from January 2011 to May 2018 at our institute. We evaluated basic demographic characteristics and radiographic parameters. All patients were treated with an LCP for primary fracture. The patients were divided into two groups: a refracture group that experienced a second fracture within 1 year after IR and a no-fracture group. @*Results@#There were four cases (1.99%) of refracture; three were treated conservatively, while one was treated surgically. All patients achieved bony union. The average interval between refracture and IR was 64 days (range, 6–210 days). There was a significant difference in classification of fractures (AO Foundation/Orthopaedic Trauma Association [AO/OTA] classification) between the two groups. However, other patient demographics and radiographic measurements between refracture and IR, such as bone diameter, showed no significant difference between the two groups. @*Conclusions@#This study showed that one in 50 patients suffered from refracture after removal of the LCP. Thus, if patients desire IR, the surgeon should explain that there is a relatively higher possibility of refracture for cases with simple or segmental fractures than for other types of fracture.

Refracture after locking compression plate removal in displaced midshaft clavicle fractures after bony union: a retrospective study

Background@#A midshaft clavicle fracture is a common fracture that typically responds well to open reduction and internal fixation (ORIF). However, refracture can occur after implant removal (IR). This study aimed to analyze the rate of refracture and related factors after removal of the locking compression plate (LCP) for displaced midshaft clavicle fractures. @*Methods@#We retrospectively reviewed the medical records of 201 patients who had undergone ORIF with LCP for midshaft clavicle fractures after IR after bony union from January 2011 to May 2018 at our institute. We evaluated basic demographic characteristics and radiographic parameters. All patients were treated with an LCP for primary fracture. The patients were divided into two groups: a refracture group that experienced a second fracture within 1 year after IR and a no-fracture group. @*Results@#There were four cases (1.99%) of refracture; three were treated conservatively, while one was treated surgically. All patients achieved bony union. The average interval between refracture and IR was 64 days (range, 6–210 days). There was a significant difference in classification of fractures (AO Foundation/Orthopaedic Trauma Association [AO/OTA] classification) between the two groups. However, other patient demographics and radiographic measurements between refracture and IR, such as bone diameter, showed no significant difference between the two groups. @*Conclusions@#This study showed that one in 50 patients suffered from refracture after removal of the LCP. Thus, if patients desire IR, the surgeon should explain that there is a relatively higher possibility of refracture for cases with simple or segmental fractures than for other types of fracture.

Survey of Preferences in Patients Scheduled for Carpal Tunnel Release Using Conjoint Analysis

BACKGROUND: This study aimed to investigate the preferences of patients scheduled for carpal tunnel release using conjoint analysis and also introduce an example of how to apply a conjoint analysis to the medical field. The use of conjoint analysis in this study is new to the field of orthopedic surgery. METHODS: A total of 97 patients scheduled for carpal tunnel release completed the survey. The following four attributes were predefined: board certification status, distance from the patient's residency, medical costs, and waiting time for surgery. Two plausible levels for each attribute were assigned. Based on these attributes and levels, 16 scenarios were generated (2 × 2 × 2 × 2). We employed 8 scenarios using a fractional factorial design (orthogonal plan). Preferences for scenarios were then evaluated by ranking: patients were asked to list the 8 scenarios in their order of preference. Outcomes consisted of two results: the average importance of each attribute and the utility score. RESULTS: The most important attribute was the physician's board certificate, followed by distance from the patient's residency to the hospital, waiting time, and costs. Utility estimate findings revealed that patients had a greater preference for a hand specialist than a general orthopedic surgeon. CONCLUSIONS: Patients considered the physician's expertise as the most important factor when choosing a hospital for carpal tunnel release. This suggests that patients are increasingly seeking safety without complications as interest in medical malpractice has increased.

Forearm Compartment Syndrome after Transradial Percutaneous Coronary Artery Intervention

Transradial percutaneous coronary artery interventions are increasingly used because of low complication rates and patients' convenience. However, the radial artery is more vulnerable to damage due to its small diameter and frequent anatomical variations. We experienced a case of forearm compartment syndrome after transradial percutaneous coronary artery intervention which has not been reported in Korean literature yet. We report the case with a review of the literature.

Bone Mineral Density and Prevalence of Osteoporosis in Postmenopausal Korean Women with Low-Energy Distal Radius Fractures

The aim of this study was to evaluate the bone mineral density and the prevalence of osteoporosis in postmenopausal Korean women with low-energy distal radius fractures and compared with those of aged-matched normal Korean women. Two hundred and six patients with distal radius fractures between March 2006 and March 2010 were included in this study. Patients were divided into three groups by age; group 1 (50-59 years), group 2 (60-69 years), and group 3 (70-79 years). Controls were age-matched normal Korean women. The bone mineral density values at all measured sites, except for the spine, were significantly lower in group 1 than those of control. While the bone mineral density values in group 2 and 3 were lower than those of controls, these differences were not statistically significant. All groups had significantly higher prevalence of osteoporosis at the Ward's triangle; however, at the spine, femoral neck and trochanteric area it was not significantly different from those of age-matched controls. Although the prevalence of osteoporosis of the postmenopausal women with low-energy distal radius fractures may not be higher than that of the control, osteoporosis should be evaluated especially in younger postmenopausal patients to prevent other osteoporotic hip and/or spine fractures.

The Effect of Distal Location of the Volar Short Arm Splint on the Metacarpophalangeal Joint Motion

BACKGROUND: The goals of this study were to compare maximal metacarpophalangeal joint (MCPJ) flexion angles after application of a volar short arm splint at 3 different locations and verify the relations between the three different physical and radiological locations. METHODS: Forty dominant hands of healthy subjects were analyzed in the study. We defined a transverse skin folding line as a line drawn from the radial aspect of the thenar crease to the ulnar aspect of the distal transverse palmar crease. The distal end of the volar short arm splint was applied on 3 parallel locations to this line. Location A was on this transverse skin folding line; location B was 1 cm proximal to location A; and location C was 1 cm distal to location A. Two orthopedic surgeons measured the maximal MCPJ flexion angles of each finger except the thumb with the application of a volar short arm splint at 3 different locations as well as without a splint as a control. Radiological locations of the 3 different distal ends of the volar short arm splint were also assessed by anteroposterior radiographs of the wrist. RESULTS: When the splint was applied at location A and C, the maximal MCPJ flexion angle decreased to a mean of 83° (91% of control value) and 56° (62% of control value), respectively (compared to the control, p < 0.001). At location B, the maximal MCPJ flexion angle was a mean of 90° (99% of control value); no significant difference was observed compared to the control or without the splint (p = 0.103). On radiography, the average length from the metacarpal head to the distal end of the splint at all fingers decreased in the order of location B, A, and C (29 mm, 19 mm, and 10 mm, respectively; p < 0.001). CONCLUSIONS: We recommend applying the distal end of a volar short arm splint at proximal 1 cm to the transverse skin folding line to preserve MCPJ motion perfectly, which is located at distal 44% of the whole metacarpal bone length radiologically.

The Effect of Distal Location of the Volar Short Arm Splint on the Metacarpophalangeal Joint Motion

BACKGROUND: The goals of this study were to compare maximal metacarpophalangeal joint (MCPJ) flexion angles after application of a volar short arm splint at 3 different locations and verify the relations between the three different physical and radiological locations. METHODS: Forty dominant hands of healthy subjects were analyzed in the study. We defined a transverse skin folding line as a line drawn from the radial aspect of the thenar crease to the ulnar aspect of the distal transverse palmar crease. The distal end of the volar short arm splint was applied on 3 parallel locations to this line. Location A was on this transverse skin folding line; location B was 1 cm proximal to location A; and location C was 1 cm distal to location A. Two orthopedic surgeons measured the maximal MCPJ flexion angles of each finger except the thumb with the application of a volar short arm splint at 3 different locations as well as without a splint as a control. Radiological locations of the 3 different distal ends of the volar short arm splint were also assessed by anteroposterior radiographs of the wrist. RESULTS: When the splint was applied at location A and C, the maximal MCPJ flexion angle decreased to a mean of 83° (91% of control value) and 56° (62% of control value), respectively (compared to the control, p < 0.001). At location B, the maximal MCPJ flexion angle was a mean of 90° (99% of control value); no significant difference was observed compared to the control or without the splint (p = 0.103). On radiography, the average length from the metacarpal head to the distal end of the splint at all fingers decreased in the order of location B, A, and C (29 mm, 19 mm, and 10 mm, respectively; p < 0.001). CONCLUSIONS: We recommend applying the distal end of a volar short arm splint at proximal 1 cm to the transverse skin folding line to preserve MCPJ motion perfectly, which is located at distal 44% of the whole metacarpal bone length radiologically.

Redisplacement of Distal Radius Fracture after Initial Closed Reduction: Analysis of Prognostic Factors

BACKGROUND: To evaluate risk factors of redisplacement and remind surgeons of key factors regarding conservative treatment of distal radius fracture. METHODS: A total of 132 patients who received conservative treatment for distal radius fractures between March 2008 and February 2011 were included in this study. Radial inclination, radial length, volar tilting angle, ulnar variance, fragment translation, and presence of dorsal metaphyseal comminution were measured on the X-rays taken immediately after reduction, one week after injury during the first follow-up outpatient clinic visit, and after the gain of radiological union. Secondary displacement was defined as a loss of reduction during the follow-up period, and was divided into 'early' and 'late' categories. We analyzed the influence of initial displacement radiologic variables, dorsal cortex comminution, and patient age on the development of secondary displacement. RESULTS: Development of secondary displacement was significantly associated only with initial displacement radiologic variables (p < 0.001), development of the late secondary displacement was significantly associated with age (p = 0.005), and initial displacement radiologic variables were associated significantly with a serial increase in ulnar variance (p = 0.003). CONCLUSIONS: Greater displacement on the initial radiographs indicates a higher possibility of development for secondary displacement, and older patients had a higher probability of late secondary displacement development. Furthermore, dorsal comminutions did not affect secondary displacement directly.

Diagnosis and Treatment for Deep Nontuberculous Mycobacteria Infection of the Hand and Wrist

PURPOSE: The purpose of this study was to present a systematic treatment method for nontuberculous mycobacteria (NTM) infection of the hand and wrist to gain better clinical outcomes. METHODS: 10 patients of deep NTM infection of the hand and wrist were reviewed. Extensive debridement was performed in all cases. When biopsy result suggested mycobacterial infection such as granulomatous inflammation, empirical tuberculosis medication was started. After culture confirmed NTM growth, the species was identified and in vitro sensitivity test was performed. Then medication was switched according to the results. Functional outcomes of the hand and wrist were measured by total active motion of the fingers and by range of motion of the wrist respectively. RESULTS: Diagnosis was tenosynovitis in seven patients, infective arthritis and osteomyelitis combined with tenosynovitis of the wrist in three patients. Two patients had recurred skin ulcer during follow-up period and undergone second debridement. After second operation, no patient had a persistent discharging sinus and all patient were completely healed during follow-up period. Functional outcome of the eight patients who had NTM infection of their hand was excellent in two, good in four, fair in one, poor in one. Mean range of motion of the two patients who had osteomyelitis of their wrist was dorsiflexion 20degrees, volar flexion 15degrees, radial deviation 0degrees, ulnar deviation 15degrees. CONCLUSION: Our standardized treatment protocol can be helpful for treatment of deep NTM infection of the hand and wrist.

Closed Reduction and Cast Immobilization for the Treatment of Distal Radius Fracture: Does Dorsal Metaphyseal Comminution Predict Radiographic and Functional Outcomes?

PURPOSE: The purpose of this study was to determine the relationship between dorsal metaphyseal comminution and the radiographic and functional outcomes of patients with distal radius fractures treated by closed reduction and cast immobilization. METHODS: Twenty-six patients with acute distal radius fractures were retrospectively reviewed. The mean age of this patient group was 62.8 years (range, 45-87 years). Eighteeen cases were AO type-A3 and 8 were AO type-A2. Radiographic and functional parameters were analyzed and compared between the patients who presented with or without dorsal metaphyseal comminution on their initial radiographs in order to assess the clinical outcomes. The radiographic parameters included radial inclination, radial length, volar/dorsal tilt, and ulnar variance. In order to measure the functional outcomes, each patient's range of motion, grip strength, Quick disabilities of the arm, shoulder, and hand (DSAH), visual analog scale (VAS), and Mayo score were determined. RESULTS: Seventeen patients (65%) presented with dorsal metaphyseal comminution on the initial radiographs. Radial inclination, radial length, and volar/dorsal tilt were decreased and ulnar variance was increased on the final radiographs in comparison with the postreduction. However, there were no statistically significant differences between the two groups that presented with or without dorsal metaphyseal comminution (p>0.05). None of the functional parameters (i.e., range of motion, grip strength, DASH, Mayo, and VAS score) were significantly different between the two groups (p>0.05). CONCLUSION: Dorsal metaphyseal comminution seems to have no significant impact on radiographic and functional outcomes when closed reduction and cast immobilization was planned for the treatment of distal radius fracture.

Musicians' Medicine: Musculoskeletal Problems in String Players

There is increasing attention to medical problems of musicians. Many studies find a high prevalence of work-related musculoskeletal disorders in musicians, ranging from 73.4% to 87.7%, and string players have the highest prevalence of musculoskeletal problems. This paper examines the various positions and movements of the upper extremities in string players: 1) basic postures for holding instruments, 2) movements of left upper extremity: fingering, forearm posture, high position and vibrato, 3) movements of right upper extremity: bowing, bow angles, pizzicato and other bowing techniques. These isotonic and isometric movements can lead to musculoskeletal problems in musicians. We reviewed orthopedic disorders that are specific to string players: overuse syndrome, muscle-tendon syndrome, focal dystonia, hypermobility syndrome, and compressive neuropathy. Symptoms, interrelationships with musical performances, diagnosis and treatment of these problems were then discussed.

Carpal Alignment Evaluation Using Three-dimensional Computed Tomography

PURPOSE: The purpose of this study was to analyze carpal alignment and evaluate the interobserver reliability of the several parameters using three-dimensional computed tomography (3D-CT) in normal Koreans. MATERIALS AND METHODS: The study included 42 wrists with no history of wrist pain or abnormality by physical examination. 3D-CT scanning was performed with each patient in zero position; the arm abduction against the trunk; the elbow flexed 90degrees; the forearm in neutral position using the stabilizing device. The three observers measured the carpal alignment parameters including distal radius articular angle, radiolunate angle, radioscaphoid angle, radiocapitate angle, radio-3rd metacarpal angle, scapholunate angle, lunocapitate angle, luno-3rd metacarpal angle. RESULTS: The mean distal radius articular anglewas 12.8degrees+/-2.6degrees, the mean radiolunate angle was 0.9degrees+/-4.6degrees, the radioscaphoid angle was 54.4degrees+/-5.3degrees, the mean radiocapitate angle was 1.7degrees+/-2.1degrees, the mean radio-3rd metacarpal angle was -1.2degrees+/-2.5degrees, the mean scapholunate angle was 53.4degrees+/-7.8degrees, the mean lunocapitate angle was 0.8degrees+/-4.7degrees and the mean luno-3rd metacarpal angle was -2.1degrees+/-5.0degrees. All parameters have excellent interobserver reliability. CONCLUSION: The normal mean values and ranges of carpal alignment angles measured by using 3D-CT may be of assistance in the evaluation of carpal alignment in patients.

Osteosynthesis with Structural Bone Grafting and Plate-screw Fixation for the Treatment of Forearm Bone Nonunion

PURPOSE: We reported clinical results of autologous tricorticocancellous bone grafting and plate-screw fixation for nonunion of the forearm bones. MATERIALS AND METHODS: Ten patients with nonunion of the forearm bones that underwent surgical treatment were evaluated. Tricorticocancellous bone grafting which was harvested from the iliac crest and plate-screw fixation were performed. Radiologic bone union was evaluated based on the simple radiographs. At the final follow-up, range of motion was measured and the Anderson scale was used for functional evaluation. RESULTS: Radiologic bone union was achieved in all cases. The mean range of motion was 139degrees of elbow flexion, 3degrees of flexion contracture, 73degrees of forearm pronation, 72degrees of supination, 70degrees of wrist flexion, and 70degrees of wrist extension. Anderson scale was excellent in 6 patients, satisfactory in three, and unsatisfactory in one. CONCLUSION: Autologous tricorticocancellous bone grafting and rigid plate-screw fixation is a reliable method to achieve successful healing of forearm bone nonunions.

Surgical Treatment of Chronic Flexor Carpi Ulnaris Tendinopathy

PURPOSE: The purpose of this study was to evaluate the results of surgical treatment in patients with chronic flexor carpi ulnaris tendinopathy. MATERIALS AND METHODS: Five patients with 7 wrists underwent surgical treatment for chronic flexor carpi ulnaris tendinopathy. The degenerative tissue inside the tendon over the pisiform was debrided and partial release of the tendon was performed. The clinical outcome was evaluated using pre and postoperative visual analogue scale (VAS) pain score and modified Mayo wrist score at the final follow-up. RESULTS: The mean VAS score was 7.3 preoperatively, which was significantly improved to 3.6 at postoperative 2 weeks, 1.9 at 6 weeks, 1.1 at 3 months, 0.7 at 6 months, and 0.7 at the final visit. Modified Mayo wrist score showed 3 excellent, 3 good, and one fair result. Biopsy showed degenerative tissue findings in all cases. CONCLUSION: Chronic flexor carpi ulnaris tendinopathy is a degenerative disease and surgical treatment of refractory cases can decrease clinical symptoms in the early postoperative period and enable patients to return to activities of daily-living.

Treatment of Recalcitrant Medial and Lateral Epicondylitis with Autologous Platelet Rich Plasma; Preliminary Report

PURPOSE: We evaluated the clinical outcomes of the autologous platelet rich plasma injection for the treatment of recalcitrant medial and lateral epicondylitis. MATERIALS AND METHODS: Nineteen cases with recalcitrant medial and lateral epicondylitis despite of conservative treatment for 1 year were enrolled in this study. Each patient underwent autologous platelet rich plasma injection and followed up minimally of 40 weeks. The assessment included a preoperative and postoperative Visual Analogue Scale (VAS) (0~10) at 4, 8, 12, 24 and 36 weeks and overall satisfaction was evaluated with Roles & Maudsley score at 36 weeks after injection. We also compared the clinical outcomes between medial and lateral epicondylitis group. RESULTS: Mean preoperative VAS was 8.7 points and improved to 5.1, 5.2 and 4.7 at 12, 24 and 36 weeks follow up, respectively. Roles & Maudsley score was excellent in 5 cases(26%), good in 7 cases(37%), acceptable in 4 cases(21%) and poor in 3 cases(16%). On the comparison of medial and lateral epicondylitis group, there was no statistical significant difference (p=0.38). CONCLUSION: The autologous platelet rich plasma injection for recalcitrant medial & lateral epicondylitis is thought to be a alternative treatment option.

Patellar Thickness in Korean Osteoarthritic Women

PURPOSE: The patellar thickness is one of the most important factors that affect patellar tracking in patients who undergo total knee arthroplasty (TKA). The purpose of this study is to help the surgeons who perform TKA by presenting basic data on the patellar thickness of the osteoarthritic Korean women. MATERIALS AND METHODS: From January 2006 to May 2007, we measured the patellar thickness of 330 patients (538 cases) who were undergoing TKA. The thickest portion of the patella was measured on a scale of 0.01 mm with using an electronic caliper before patellar osteotomy. We analyzed the data to determine the relationships between the patellar thickness and the patients' age, height, weight and BMI, and the osteoarthritic change of the patella. RESULTS: The average thickness was 21.37+/-1.43 mm. There was a statistically significant positive relation of patellar thickness with weight and height and a negative relation with the degree of osteoarthritis. Age and BMI were not related with the patellar thickness. CONCLUSION: The average thickness was 21.37+/-1.43 mm and it was closely related with weight and height and the osteoarthritic change of the patella.