Avulsion fractures of the scaphoid and triquetrum in a 15 year- old male.

Avulsion fractures of the perilunate ligaments occur in isolation, and multiple fractures are typically not seen in the same carpus. We present a case of a 15-year-old male who injured his wrist during football practice. He presented without wrist dislocation or deformity. Radiographs demonstrated avulsion fractures to the proximal pole of the scaphoid and proximal radial aspect of the triquetrum. The patient was immobilized with an upper extremity thumb spica cast; however, there was persistent non-union of both fractured segments. Magnetic resonance imaging confirmed avulsions at the site of the scapholunate and lunotriquetral ligaments, with both ligaments relatively intact. At the last follow-up, one year after the initial injury, the patient had a normal clinical exam, with no pain and full wrist range of motion despite fracture non-union at both locations. This is a unique injury with an unclear mechanism and complicated management.

Double fascicular nerve transfer for elbow flexion and extension.

Traumatic brachial plexus injuries are life changing, often leaving affected individuals with severe functional deficits. Recent advances in nerve transfers have allowed surgeons to improve elbow flexion, shoulder abduction, and prehension of the hand in some patients. We hypothesize that in a patient who lacks both biceps and triceps function, a double fascicular transfer may be the key to restore elbow flexion and extension. In three cadaver upper limbs, we transferred the expendable motor fascicle of the ulnar nerve to the biceps branch of the musculocutaneous nerve, and the expendable motor fascicle of the median nerve to the triceps (ulnar collateral) branch of the radial nerve. We evaluated the feasibility of this double nerve transfer via a medial approach, and elucidated the anatomy. The transfers were easily performed and were tension-free throughout full range of motion at the elbow. The triceps branch of the radial nerve that we utilized has a length of approximately 4.9 cm, and is best found between 3.5 and 6 cm from the anterior axillary line. We consistently identified a relatively avascular plane in the region between 7.5 and 11 cm from the anterior axillary line, which corresponds with the recipient sites of the medial head of the triceps. The distance between the triceps branch to the median nerve was an average of 2.5 cm. Transfer of expendable motor fascicles from the ulnar and median nerves to the biceps and triceps nerve branches can be successfully and consistently performed through a medial approach in a cadaver.

Carpal coalition: A review of current knowledge and report of a single institution's experience with asymptomatic intercarpal fusion.

BACKGROUND: Carpal coalition is a relatively common, yet poorly recognized, anomaly that may present independently or in association with syndromic or metabolic disorders. While largely asymptomatic, symptoms may manifest secondary to biomechanical stress at the site of fusion. The purpose of this report is to describe 103 cases of carpal synostosis and provide a review of the etiology, classification, and clinical significance of intercarpal fusion. METHODS: Retrospective review of medical and radiographic records was conducted on all patients with identified carpal coalitions, between 2008 and 2012, at our institution. Demographic and historical data regarding trauma, infection, documented joint disease, and prior wrist symptomatology were analyzed for each case, and radiographic evaluation of carpal alignment was performed. RESULTS: A total of 103 cases of carpal coalition, among 85 individuals, were reviewed. All cases presented asymptomatically with the highest proportion noted among individuals of African-Caribbean descent. The most frequent variant in our study population was lunate-triquetral coalition, which was present in 92 of the 103 identified cases. None of the cases evaluated in this study demonstrated clinical or radiographic evidence of carpal mal-alignment or instability. CONCLUSION: The results of our investigation demonstrate that carpal coalition presented most frequently among individuals of African-Caribbean descent. While the prevalence of this condition has yet to be studied specifically in Hispanic and African-Caribbean populations, our findings may reflect the genetic linkage between these and certain West African populations. To our knowledge, this represents the largest clinical series of carpal coalition in the English literature.

Resident selection of Hand Surgery Fellowships: a survey of the 2011, 2012, and 2013 Hand Fellowship graduates.

BACKGROUND: We desired information from the recent, current, and future matched hand surgery fellows regarding their residency training, number of interviews, position matched, cost of interviewing, influences, opinions on future hand training models, and post-fellowship job information. METHODS: Institutional review board approval was obtained from our institution to submit an online survey. An email was sent to the coordinators of all US Hand Fellowships to be forwarded to their fellows with graduation years 2011, 2012, and 2013, as well as directly to the fellows if their email addresses were provided. Data on the application process, relative importance of program attributes, and opinions regarding optimal training of a hand surgeon were collected. Statistical analysis was performed with respect to the training background and graduation year of the respondent. RESULTS: The survey was completed by 137 hand surgery fellows. Seventy-one percent of the survey responders were from an orthopedic residency background, 20 % from plastic, and 7 % from general surgery. Forty-four percent of all of the respondents matched into their first choice. The type of operative cases performed by the current fellows was most often selected as very important when making their rank list. Seventy-seven percent of the respondents reflected their personal preference in fellowship model to be a 1-year fellowship program. CONCLUSIONS: The field of hand surgery is unique in that it has residents from multiple training backgrounds who all apply to one fellowship. The current fellowship model allows for diversity of training and the possibility of obtaining a second fellowship if desired.

Novel wire external fixation technique for proximal phalanx pilon fractures: technique and 2 case reports.

Unstable, severely comminuted fractures of the base of the proximal phalanx are often difficult to treat. We have been treating pilon-type fractures about the metacarpophalangeal joint using a novel external fixation technique with success. We present 2 examples of comminuted base of proximal phalanx fractures were treated successfully using the distraction external fixation with excellent outcomes. We believe that our technique is easily reproducible, relatively inexpensive, facilitates wound care, and enables early mobilization.

Wrist anatomy and surgical approaches.

Appreciation and knowledge of anatomy as it relates to surgical approaches is critical for planning treatment of traumatic wrist injuries. This article discusses the pertinent anatomy and some of the more commonly used approaches to wrist trauma.

Wrist anatomy and surgical approaches.

Appreciation and knowledge of anatomy as it relates to surgical approaches is critical for planning treatment of traumatic wrist injuries. This article discusses the pertinent anatomy and some of the more commonly used approaches to wrist trauma.