Conversion of external fixation to open reduction and internal fixation for complex distal radius fractures.

INTRODUCTION: Distal radius fractures are common injuries treated in a multitude of ways. One treatment paradigm not extensively studied is initial treatment by external fixation (EF) followed by conversion to open reduction internal fixation (ORIF). Such a paradigm may be beneficial in damage control situations, when there is extensive soft tissue injury, or when appropriate personnel/hospital resources are not available for immediate internal fixation. HYPOTHESIS: There is no increased risk of infection when converting EF to ORIF in the treatment of complex distal radius fractures when conversion occurs early or if EF pin sites are overlapped by the definitive fixation. MATERIALS AND METHODS: Using an IRB approved protocol, medical records over nine years were queried to identify patients with distal radius fractures that had undergone initial EF and were later converted to ORIF. Charts were reviewed for demographic data, injury characteristics, operative details, time to conversion from EF to ORIF, assessment of whether the EF pin sites overlapped the definitive fixation, presence of infection after ORIF, complications, and occupational therapy measurements of range of motion and strength. RESULTS: In total, 16 patients were identified, only one of which developed an infection following conversion to ORIF. Fisher's exact testing showed that infection did not depend on open fracture, time to conversion of one week or less, presence of EF pin sites overlapping definitive fixation, fracture classification, high energy mechanism of injury, or concomitant injury to the DRUJ. DISCUSSION: Planned staged conversion from EF to ORIF for complex distal radius fractures does not appear to result in an increased rate of infection if conversion occurs early or if the EF pin sites are overlapped by definitive fixation. This treatment paradigm may be reasonable for treating complex distal radius fractures in damage control situations, when there is extensive soft tissue injury, or when appropriate personnel/hospital resources are not available for immediate internal fixation. LEVEL OF EVIDENCE: IV, retrospective case series.

Ulnar tunnel syndrome.

Compression neuropathies are a significant source of pain in the upper extremity. Although ulnar tunnel syndrome occurs much less frequently than cubital tunnel syndrome, compression of the nerve at this level is a readily treatable condition. Ulnar tunnel syndrome should be kept in the differential diagnosis when the patient complains of numbness of the ring and small fingers, hand weakness, and pain on the ulnar side of the wrist.

Osteoid osteoma of the upper extremity.

Osteoid osteomas, relatively rare lesions in the upper extremity, can be a persistent source of hand or wrist pain. Patients under age 40 who have otherwise unexplained pain should be evaluated. Relief of pain with oral nonsteroidal anti-inflammatory drugs should suggest the possibility of osteoid osteoma. Examination may demonstrate localized swelling or joint effusion. Radiographs should be examined for sclerosis in the region of pain. If radiographs are nondiagnostic, a bone scan should be obtained. If the nidus cannot be clearly visualized by radiography and bone scan, a CT scan should be obtained. If the location of the nidus makes excision difficult without removal of a large block of bone, localization with a CT-guided needle or by radioisotope labeling will help to assure removal of the nidus.

Management of intra-articular fractures of the metacarpophalangeal joint.

Displaced intra-articular fractures of the metacarpal head and of the proximal articular surface of the proximal phalanx often require open reduction and internal fixation, particularly if an articular step off is present. If secure internal fixation can be achieved, early motion may be instituted. Diagnosis may be facilitated by special views and tomography. Secondary reconstructive procedures may include tenolysis, osteotomy, arthroplasty, or tissue transfer from the foot.

Complications of the treatment of cubital tunnel syndrome.

Cubital tunnel syndrome is the most common entrapment of the ulnar nerve. Complications in the treatment of cubital tunnel syndrome may be caused by errors in diagnosis, errors in conservative management, and errors of surgical treatment. This article discusses each cause of complications separately, with a division in errors of surgical treatment into complications from decompression of the ulnar nerve, medial epicondylectomy, anterior transposition of the ulnar nerve, intramuscular transposition of the ulnar nerve, subcutaneous transposition of the ulnar nerve, submuscular transposition of the ulnar nerve, and failed surgical treatment.

Osteoid osteoma of the upper extremity.

Forty-six patients with histologically confirmed osteoid osteoma of the upper extremity seen from 1947 to 1990 were retrospectively reviewed. The patients' age at presentation averaged 20 years. Twenty-four of the lesions were located in the wrist and hand and 22 in the arm and forearm. The average duration of symptoms before diagnosis was 15 months. Pain was the presenting symptom in 44 of 46 patients. Of the 28 patients who took aspirin for pain, 24 obtained at least partial relief. A mass or swelling was more commonly noted in lesions of the hand and wrist as compared to the arm and forearm. The diagnosis of osteoid osteoma was made by plain x-ray films alone in 35 cases. Bone scans were performed on 13 patients; all were positive at the site of the lesion. Tomography was performed in 13 cases to identify the intraosseous location of the lesion. All lesions were treated by excision and curettage. Thirty-four of the 46 patients were followed at our institution for more than 6 months, with an average follow-up period of 27 months. Six of the patients had persistent lesions. Of the six persistent osteoid osteomas, five occurred in the wrist or hand (p = .0012). A total of 15 procedures were required to excise these lesions.

The microvasculature of the triangular fibrocartilage complex: its clinical significance.

The microvascular anatomy of the triangular fibrocartilage complex was investigated in 10 cadaver specimens by histology and tissue clearing (Spalteholz) techniques. It was found that the triangular fibrocartilage of the wrist is supplied by small vessels that penetrate the triangular fibrocartilage complex in a radial fashion from the palmar, ulnar, and dorsal attachments of the joint capsule and supply the peripheral 10% to 40%. The inner (horizontal) portion is avascular, and no vessels cross the radial attachment of the triangular fibrocartilage complex. The results of this study suggest that tears in the periphery of the triangular fibrocartilage complex may have sufficient blood supply to mount a reparative response and, in theory, can be repaired. However, tears that occur in the center and along the radial attachment do not have immediate access to a blood supply and are not likely to heal.

Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia.

A long-term retrospective study of patients with chronic paronychia treated by eponychial marsupialization with or without nail removal is presented. Twenty-eight consecutive fingers with chronic paronychia in twenty-five patients were surgically treated. Symptoms had been present for 28 +/- 7 weeks. Twenty-three of these had nail irregularities. Of this group, the first seven fingers were treated with marsupialization alone. Recurrences developed in two of these. The next sixteen patients with nail irregularities were treated with marsupialization plus nail removal, and there were no recurrences (p less than 0.05). Furthermore, when the two recurrent paronychia were treated with both procedures, one healed completely and the other was markedly improved. All fingers without nail irregularities healed with marsupialization alone. These results confirm that eponychial marsupialization is an effective means of treating chronic paronychia and suggest that nail removal should be done when concurrent nail irregularities are seen.

Effect of purified human interleukin-1 on cartilage degradation.

The effects of highly purified human monocyte-derived interleukin-1 (IL-1) on bovine nasal cartilage breakdown were investigated. Cartilage degradation was determined by quantifying the fraction of total proteoglycan released from cartilage during 8 days of culture. The response appeared to be chondrocyte-dependent, for IL-1 stimulated proteoglycan (PG) release from living but not from dead (frozen-thawed) cartilage. IL-1 action on living cartilage was heat labile and concentration dependent, with significant effect at 5 U/ml and maximal effect at 10-20 U/ml. Kinetic studies showed significant stimulation of PG release by 3 days of incubation with 10 U/ml IL-1. Studies in which IL-1 was removed on day 1 or day 4 showed that the cartilage-degrading effect of this monokine was reversible. Although IL-1 caused little change in the Sepharose CL-2B chromatographic profile of released PGs using an associative elution buffer, a significant shift to lower mol wt was observed under dissociative conditions. To probe the mechanism of IL-1 action, cartilage samples were incubated with IL-1 in the presence of the protein synthesis inhibitor, cycloheximide, or the lysosomal membrane-stabilizing steroid, hydrocortisone. Cycloheximide at 5-10 micrograms/ml completely blocked IL-1-induced breakdown. One the other hand, 3 x 10(-7) M hydrocortisone had little or no effect on IL-1 action. IL-1 was also shown to stimulate the degradation of human articular cartilage.

Cyclic AMP-regulating agents inhibit endotoxin-mediated cartilage degradation.

The influence of cyclic AMP on cartilage degradation was investigated by using phosphodiesterase inhibitors [theophylline and 3-isobutyl-1-methylxanthine (IBMX)], forskolin (which activates the catalytic subunit of adenylate cyclase) and cyclic AMP analogues (dibutyryl and 8-bromo). Breakdown was assessed by quantification of proteoglycans released into the media of 8-day bovine nasal-septum cartilage cultures. Theophylline (1-20 mM), IBMX (0.01-2 mM) and dibutyryl cyclic AMP (0.1-2 mM) had little or no influence on the rate of proteoglycan release from unstimulated (no-endotoxin) cartilages. A small but detectable increase in breakdown was observed with 8-bromo cyclic AMP (0.5-2 mM) and forskolin (50-75 micrograms/ml). To examine potential inhibitory influences of these agents, the cyclic AMP modulators were added to cultures simultaneously treated with Salmonella typhosa endotoxin (12-25 micrograms/ml), a potent stimulator of cartilage degradation. The 3-4-fold stimulation of breakdown by endotoxin was strikingly inhibited by all three classes of cyclic AMP regulators. Optimal inhibition was found at 10-20 mM-theophylline, 1-2 mM-IBMX, 50-75 micrograms of forskolin/ml, 2 mM-dibutyryl cyclic AMP and 2 mM-8-bromo cyclic AMP. Inhibition was shown to be reversible, indicating that cartilages were viable after treatment. Sepharose CL-2B chromatography of proteoglycan products released from treated cartilages showed that the endotoxin-stimulated shift to lower average Mr was significantly prevented by cyclic AMP analogues and phosphodiesterase inhibitors. Together, these results show that agents which increase cyclic AMP inhibit both quantitative and qualitative aspects of endotoxin-mediated cartilage degradation.