Comparing internal and external stabilization for traumatic elbow instability: a systematic review.

Background: Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS. Methods: A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment. Results: The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals. Discussion: The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.

Scaphoid fracture and nonunion: new directions.

The scaphoid is the largest of the carpal bones, articulating with both proximal and distal carpal rows. If scaphoid fractures are not appropriately diagnosed and treated, there is a risk of nonunion, osteonecrosis and degenerative arthritis. Operative management of the scaphoid fracture is primarily determined by the fracture location and amount of displacement. There is increased momentum for dual screw fixation constructs, intended to provide greater stability and reduce the risk of nonunion. Our current practice is to utilize two screws without graft as a first-line treatment for scaphoid nonunion with or without humpback deformity and cyst formation. This review will discuss the management of acute scaphoid fractures and the treatment of nonunion.

A Medial Approach That Provides Ample Exposure of the Coronoid for Fracture Management.

We describe a medial approach to the coronoid where the flexor-pronator mass is released from its humeral origin by creating a proximally based tendinous flap. This technique facilitates access to the coronoid, preservation of the medial collateral ligament origin, and repair of the flexor-pronator mass. This approach has utility for all coronoid fracture variations but especially the O'Driscoll anteromedial subtype 3, which includes fractures of the sublime tubercle, the anteromedial facet, and the coronoid tip.

Linking the distal humerus columns in articular fracture fixation.

INTRODUCTION: Concerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture. MATERIALS AND METHODS: Ten matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths. RESULTS: Mean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94). DISCUSSION: Our results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments.

Double Barrel Screw Fixation for Proximal Phalanx Fracture.

A variety of fixation options exist for treatment of unstable proximal phalanx fractures. Variables which require consideration include the strength of fixation, the invasiveness of the technique and the postoperative rehabilitation protocol. Here we present a minimally invasive technique for dual headless compression screw fixation of proximal phalanx fractures which reduces extensor tendon violation and allows early motion in the immediate postoperative period.

Radiography of the Distal Radius.

SUMMARY: Imaging of the distal radius is of paramount importance in diagnosing injuries, indicating patients for operative or nonoperative treatment, and appropriately following patients for associated injuries and complications. Plain radiographs and fluoroscopy are the dominant imaging modalities in all settings because they are readily available and provide valuable information about the osseous structures and any instrumentation. Computed tomography can offer more information about implant placement and the level of comminution of the articular surfaces but is more expensive and exposes patients to higher doses of radiation. Magnetic resonance imaging is less commonly used but is useful for occult fractures and other associated injuries. Ultrasonography is gaining popularity in evaluating implant placement, especially regarding tendon impingement and subsequent tendon injury.

Optimal detection of scapholunate ligament tears with MRI.

Background Scapholunate interosseous ligament (SLIL) injuries can often be difficult to detect using magnetic resonance imaging (MRI), especially with older 1.0 and 1.5 Tesla magnets. Wrist arthroscopy is the gold standard for diagnosis of SLIL injuries, but is an invasive procedure with associated risks. Purpose To assess whether SLIL injuries can be more accurately detected using axial MRI sequences instead of coronal sequences. Material and Methods An institutional review board approved retrospective analysis of arthroscopic wrist surgeries performed at our institution. Patients that had a preoperative MRI performed at our university center using a 1.5 Tesla scanner with a dedicated wrist coil were included in the study. Three fellowship-trained musculoskeletal radiologists reviewed the axial sequences and coronal sequences independently. The accuracy of the coronal and axial sequences was compared with the arthroscopic/surgical findings. Result Twenty-six patients met the inclusion criteria. The sensitivity for SLIL tears was 79% and 65% for the axial and coronal sequences, respectively. The specificity was 82% for the axial and 69% for the coronal sequences, respectively. The positive and negative predictive values for the axial sequences were 76% and 84% respectively, compared to 68% and 71% for the coronal sequences, a statistically significant difference. Conclusion SLIL tears are more readily detectable on axial MRI sequences than coronal. Clinically, patients with radial-sided wrist pain and suspicion for SLIL tears should have the axial sequences scrutinized carefully. An otherwise normal study with the axial sequence being degraded by motion or other MRI artifacts might need repeat imaging.

Hibernomas of the upper extremity: a case report and literature review.

Hibernomas are rare, benign tumors of brown adipose tissue. While they have been found in a variety of locations, they are rare in the upper extremity and not previously described in the hand. Diagnosis is most often made histologically, and treatment consists of surgical resection. We present an unusual case of hibernoma in the hand treated with marginal excision, resulting in good function, cosmesis, and no recurrence.

Comparative analysis of photograph-based clinical goniometry to standard techniques.

BACKGROUND: Assessment of joint range of motion (ROM) is an accepted evaluation of disability as well as an indicator of recovery from musculoskeletal injuries. Many goniometric techniques have been described to measure ROM, with variable validity due to inter-rater reliability. In this report, we assessed the validity of photograph-based goniometry in measurement of ROM and its inter-rater reliability and compared it to two other commonly used techniques. METHODS: We examined three methods for measuring ROM in the upper extremity: manual goniometry (MG), visual estimations (VE), and photograph-based goniometry (PBG). Eight motions of the upper extremity were measured in 69 participants at an academic medical center. RESULTS: We found visual estimations and photograph-based goniometry to be clinically valid when tested against manual goniometry (r avg. 0.58, range 0.28 to 0.87). Photograph-based measurements afforded a satisfactory degree of inter-rater reliability (ICC avg. 0.77, range 0.28 to 0.96). CONCLUSIONS: Our study supports photograph-based goniometry as the new standard goniometric technique, as it has been clinically validated, is performed with greater consistency and better inter-rater reliability when compared with manual goniometry. It also allows for better documentation of measurements and potential incorporation into medical records in direct contrast to visual estimation.

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.

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.