Dynamic digital traction for unstable comminuted intra-articular fracture-dislocations of the proximal interphalangeal joint.

Unstable intra-articular fracture-dislocations about the proximal interphalangeal joint present a formidable management dilemma. Fourteen patients with comminuted injuries of the proximal interphalangeal joint were treated with dynamic digital traction and followed for an average of 24 months. Dorsal fracture-dislocation and pilon-type injuries made up the majority of cases. Average proximal interphalangeal joint articular surface involvement was 80%. Immediate motion was instituted after traction application. The device was applied in the office with readily available materials. At final follow-up examination, active arc of motion averaged 89 degrees at the proximal interphalangeal joint and 95 degrees for patients sustaining isolated injuries. X-ray films revealed fracture union, joint remodeling, and preservation of joint space. Patient satisfaction was high, with return to previous levels of activity and excellent functional joint restoration. Dynamic digital traction is recommended for unstable proximal interphalangeal joint fractures with comminution, including those associated with subluxation or dislocation.

Tibial bone density loss in spinal cord injured patients: effects of FES exercise.

A group of 37 spinal cord injured (SCI) patients underwent bone density measurements at the distal and proximal end of the tibia by a special computed tomography scanner, the OsteoQuant. Fifteen of these patients had follow-up measurements while enrolled in a lower-limb exercise training program with functional electrical stimulation (FES). The pre-exercise measurements revealed a strong correlation (0.88 < or = r < or = 0.90) of trabecular, subcortical, and cortical bone density between the distal and proximal ends of the tibia. The expected bone density loss during the first two years post injury (as calculated from the regression lines of bone density vs. time post injury) amounted to 51.5% for trabecular, 44.2% for subcortical, and 32.7% for cortical bone. No major bone density loss was calculated after 7 years post injury. Analysis of the bone density data during the FES exercise program revealed various degrees of loss. However, the rate of bone loss for this FES exercise group was less than expected from the regression lines. The reduction of bone loss was between 0.2 and 3.3% per year, and was significant (p < 0.05) for all bone parameters at the distal end and for trabecular bone density at the proximal end of the tibia. These bone density measurements revealed a potentially positive effect of FES exercise intervention for the rehabilitation of SCI patients.

A scaphoid fracture associated with a displaced distal radial fracture in a child.

A hyperextension injury to the wrist caused a transverse scaphoid fracture associated with a displaced distal radial fracture in an 11-year-old boy. Anatomic reduction and immobilization in a long-arm cast for a period of 12 weeks resulted in subsequent healing of these fractures. The coexistence of a scaphoid fracture with a distal radius fracture in a child is important to recognize because reduction maneuvers are modified to effectively treat this combination of injuries. Patients with distal radial physeal injuries should be closely evaluated for clinical and roentgenographic signs of scaphoid fractures.

Congenital vascular abnormalities in Okihiro's syndrome--a case report.

In this report, the authors describe the angiographic findings in the forearm and hand in Okihiro's syndrome. To the best of their knowledge, it has not been described before. Okihiro et al described hypoplasia of the thenar eminence in association with a congenital disorder of ocular motility previously reported in Duane's syndrome.

Vascular insufficiency in Okihiro's syndrome secondary to hypothenar hammer syndrome.

The presence of Okihiro's syndrome (congenital thenar hypoplasia and Duane's anomaly) in a patient became clinically significant when a hypothenar hammer syndrome developed. The ulnar artery occlusion resulted in a compromise of the hand's vascular supply because of a congenital hypoplastic radial artery. Resection of the thrombosed ulnar artery and insertion of an interposition vein graft restored circulation to the hand. Anatomic features in this case include a hypoplastic radial artery and double motor branch of the median nerve. Clinicians should consider Okihiro's syndrome in the differential diagnosis of thenar muscle atrophy since there are genetic, diagnostic, and clinical implications.

Multiplicity of neurilemomas in the upper extremity.

Multiple neurilemomas in two patients show that these tumors may indeed be multiple, may involve the same nerve trunk, may occur over a period of years, and may involve different regions of the body. Twelve neurilemomas were removed from the right upper extremity of a patient over a 3-year period. They varied in size from 0.5 cm to 4 cm in diameter and had the typical histopathologic appearance of neurilemomas. The second patient had median nerve compression and at operation a neurilemoma was found compressing the nerve. Two years later, the patient had evidence of median nerve compression in the opposite extremity, and again a neurilemoma was found. Both of these patients had evidence of peripheral nerve compression, but the existence of multiple neurilemomas was not apparent on initial examination. These cases show that patients with neurilemomas may have additional sequential tumors discovered at a later date that were not apparent initially.

The plantar ecchymosis sign in fractures of the calcaneus.

The appearance of a central plantar ecchymosis is not an uncommon occurrence 24-48 hours after a compression fracture of the calcaneus. In order to understand the development of this characteristic ecchymosis, the authors studied the anatomy of the fascial compartments in five adult cadaveric feet. The anatomic basis for the plantar ecchymosis sign is demonstrated through dissection of the three osteofascial compartments within the sole of the foot. Dye injected into the central compartment overlying the calcaneal tuberosity reproduces the observed clinical sign. The specificity of this sign for compression fractures of the calcaneus makes it a useful clinical observation in cases where the diagnosis of fracture is uncertain.

Late skeletal deformities following meningococcal sepsis and disseminated intravascular coagulation.

Late skeletal deformities following meningococcemia associated with disseminated intravascular coagulation are rare. Two basic lesions have been described: epiphyseal avascular necrosis and epiphyseal-metaphyseal defects. These occur primarily in the lower extremities and result in angular deformity and leg length inequality. We recently encountered these lesions in a child 3 years following sepsis. The etiology appears to be acute vascular thrombosis of epiphyseal and metaphyseal vessels mediated through the generalized Shwartzman reaction. An increased incidence of these deformities may be anticipated as more children survive fulminant meningococcemia.