Acute injuries of the extensor tendons proximal to the metacarpophalangeal joints.

The results of acute repair of the extensor tendons proximal to the metacarpophalangeal joint vary with the degree of associated injuries. Shortening should be kept to a minimum at the time of repair. The Kleinert modification of the Bunnell technique affords the greatest tensile strength. A 3-0 or 4-0 nonabsorbable suture on a small tapered needle should be used. The extensor retinaculum should be resected or transposed for injuries in zones VII and T V. Sensory branches of the ulnar and radial nerves should be repaired primarily, if possible. The most frequent complication is loss of metacarpophalangeal joint flexion secondary to tendon adhesions. The more complex the wound, the greater the indication for controlled mobilization.

Secondary reconstruction after vascularized fibular transfer.

We evaluated the results of skeletal reconstruction performed through a mature, vascularized fibular graft in five patients. The average time-interval between the original transplant and the secondary reconstruction was sixty-eight months. The indication for the initial graft had been the loss of bone secondary to trauma in one patient, a skeletal defect due to ablation of a tumor in two patients, and osseous loss due to resection of a congenital pseudarthrosis in two patients. The indication for the second reconstruction was non-union of a fracture as a result of a new traumatic injury in two patients and complex angular deformity in three patients; one of the patients in the latter group had an associated leg-length discrepancy. In all five patients, the second reconstruction was successful, and the vascularized fibular graft responded to the procedure in a manner similar to normal cortical bone.

An anatomical variation of the palmar cutaneous branch of the median nerve.

A case is presented of an anomalous course of the palmar cutaneous branch of the median nerve. Wide and meticulous exposure is necessary to avoid injury to all variations of this nerve and the use of a "safe" incision will not always avoid risk of injury.

Variations of the ulnar nerve. A surgical perspective.

A systematic review of ulnar nerve variations is presented. Many of these anomalous neural structures account for the atypical clinical or electromyographic findings that are often a source of diagnostic confusion. Knowledge of these variations will hopefully lessen the likelihood of inadvertent injury and consequent motor and/or sensory loss.

A survey of patients with Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is an inherited disorder of collagen biosynthesis. Nine types of the disorder are now recognized. A survey of 151 EDS patients showed a high percentage of the patients were classified as having Types I through IV. Bracing and fusion appear to be the most commonly used methods of orthopedic care. Surgical complications were common. The orthopedist was often the first practitioner to diagnose and treat the patient with EDS. A fundamental understanding of this complex disorder and its varied manifestations is essential to prevent major life-threatening complications.

Anatomical variations of the median nerve at the wrist.

A comprehensive review of reported median-nerve variations at the wrist is presented. This includes motor-branch anomalies, multiple divisions of the median nerve, neural loops, and variations in association with aberrant muscles. Inadvertent injury to the median nerve during carpal tunnel surgery can be minimized if the anatomy is understood, variations are recognized, and adequate exposure is achieved.

Intraosseous ganglia of the carpal bones.

Intraosseous ganglia are benign, cystic lesions of bone that are most commonly found in the subchondral region of long bones of the lower extremity. Reports of isolated carpal involvement are rare; however, it has been well documented that these lesions may produce chronic wrist pain. Various theories of pathogenesis have been advanced, including synovial herniation, mucoid degeneration, primary cellular metaplasia, and chronic repetitive trauma. In our study, 11 patients (seven female, four male) with 12 lesions were treated for chronic wrist pain associated with intraosseous carpal ganglia. All patients had similar complaints preoperatively and were unable to obtain relief with rest, immobilization, or nonsteroidal medication. Aside from local tenderness over the involved bone, the physical examination was unremarkable. Acute trauma was not found to be a factor in any of these patients' histories. Eleven lesions in 10 patients were grafted with bone from the distal radius. A complete resolution of symptoms was seen at a 20-month follow-up examination.

Sensory neural loop of the median nerve at the carpal tunnel.

This article discusses a sensory neural loop on the radial aspect of the median nerve in the palm. The surgeon should be aware of this anomaly when the transverse carpal ligament is divided to approach the structures contained in the carpal canal.

The failed ulnar nerve transposition. Etiology and treatment.

Various procedures have been recommended for the treatment of cubital tunnel syndrome. Simple decompression in situ, medial epicondylectomy, subcutaneous transposition, intramuscular transposition, and submuscular transposition all have their advocates. The results of the surgical treatment for cubital tunnel syndrome are related to the severity of the compressive neuropathy at the time of diagnosis and to the adequate decompression of the nerve at all sites of potential compression at the time of surgical treatment. Fourteen patients who had previously undergone surgical treatment for cubital tunnel syndrome were evaluated because of persistent pain, paresthesia, numbness, and motor weakness. All patients had documented persistent compression of the ulnar nerve on clinical and electromyographic evaluation. The indication for repeat surgical exploration in all patients was unremitting pain despite nonoperative treatment. All patients had been treated by neurolysis and submuscular transposition of the ulnar nerve as described by Learmonth. The causes of continued pain after initial surgery included retention of the medial intermuscular septum, dense perineural fibrosis of the nerve after intramuscular and subcutaneous transposition, adhesions of the nerve to the medial epicondylectomy site, and recurrent subluxation of the nerve over the medial epicondyle after subcutaneous transposition. Revision surgery was found to be highly successful for relief of pain and paresthesias; however, the recovery of motor function and return of sensibility were variable and unpredictable.

Acute injuries of the distal radioulnar joint.

Acute injuries of the distal radioulnar joint are common. They often are not treated aggressively owing to a failure to diagnose or the misconception that there is little functional impairment if left untreated. Early aggressive treatment with restoration of anatomic alignment and stability will yield optimum results. Acute treatment usually produces a better functional outcome than late reconstructive procedures.

A neural loop of the deep motor branch of the ulnar nerve: an anatomic study.

A motor neural loop of the deep branch of the ulnar nerve was encountered on three occasions during neurolysis of the ulnar nerve through Guyon's canal. An anatomic study of the course of the deep motor branch of the ulnar nerve at the wrist was done to define the incidence of this neural loop. Seventy-seven cadaveric upper extremities were examined and seven (9%) cases of a neural loop were encountered. One of these cases was bilateral. This variation should be considered when there is an atypical clinical presentation after penetrating injuries or compression neuropathy of the ulnar nerve at the wrist. In addition, care must be taken not to injure this branch during decompression of Guyon's canal or excision of an ununited of the hook of the hamate.

Neurovascular injuries in the hands of athletes.

Neurovascular injuries are rare in the athlete. Prevention is the ultimate goal. Modification of protective devices, alteration of technique, and education may help avoid some of the neurovascular problems described in this article. Early recognition and appropriate conservative treatment may alleviate the need for surgical intervention.

The independent long extensor tendon of the fifth toe as a source of tendon grafts for the hand.

The anatomical relationships of the extensor of the fifth toe to the long extensor of the other toes have been studied in 78 cadaver specimens. 50% of the specimens had an independent extensor to the fifth toe without interconnections to the other long toe extensors or the peroneus tertius. The independent fifth toe extensor was consistently of good quality and adequate length for use as a tendon graft, for which purpose it has been successfully used in five patients, with transfer of the adjacent long extensor from the fourth toe to maintain extension of the fifth metatarso-phalangeal joint.

Variation of the deep motor branch of the ulnar nerve at the wrist.

An unusual variation in the course of the deep motor branch of the ulnar nerve is described. This anomaly should be kept in mind during operations for fractures of the hook of the hamate and also in atypical clinical patterns of denervation caused by trauma or compressive neuropathies.

Radiographic evaluation of the hook of the hamate: a new technique.

Radiographic confirmation in cases of suspected hook of hamate fractures can be very difficult. Films, including the carpal tunnel view, may be difficult to interpret. We describe a new semisupine oblique radiographic view of the carpus that permits excellent visualization of the hamate hook, is cost efficient, and allows for patient comfort during the study.

The optimal position for arthrodesis of the metacarpophalangeal joint of the thumb: a clinical study.

Arthrodesis of the metacarpophalangeal joint of the thumb is a well-accepted procedure. Recommendations for position of fusion have varied from 0 to 30 degrees of flexion. Two hundred of these joints in normal subjects were measured in thirteen positions of function for different tasks. The mean of all thirteen measured positions was considered to be the "optimal functional position". Based on this study, we recommend the metacarpophalangeal joint of males be fused in approximately 25 degrees of flexion and females in 20 degrees of flexion.

Displaced intra-articular glenoid fractures treated by open reduction and internal fixation.

Displaced intra-articular glenoid fractures are extremely rare. Anatomic reduction, rigid internal fixation and early mobilization restored a full, painless range of motion in our two cases.

Open elbow dislocation with brachial artery disruption: case report and review of the literature.

Open dislocations of the elbow are rare, while associated vascular injuries are common. The recommended method of treatment in a pulseless dislocated extremity is reduction, stabilization and vascular repair by interpositional vein grafting.