Pediatric floating elbow.

SUMMARY: A retrospective review of 16 patients with floating elbow injuries over a 9-year period at a tertiary care children's hospital confirms that these injuries are associated with substantial swelling and the potential to develop compartment syndrome, particularly when circumferential cast immobilization is used. Among 10 patients in whom the forearm was treated with closed reduction and plaster immobilization, a compartment syndrome developed in 2, and 4 patients had incipient compartment syndrome that responded to splitting of the cast; 3 of these subsequently required remanipulation of the distal radius. One patient with compartment syndrome had Volkmann ischemic contracture. Six patients underwent stabilization of both the distal humeral and forearm fractures with percutaneously inserted Kirschner wires, thereby allowing postreduction immobilization in a split cast. None of these patients had problems with excessive swelling or compartment syndrome. Percutaneous Kirschner wire fixation of both the humeral and forearm fractures in pediatric floating elbow injuries allows noncircumferential immobilization, thereby reducing the risk of compartment syndrome.

Epicondylitis--lateral and medial. A problem-oriented approach.

Epicondylitis will remain a problematic condition until we better understand the nature of the degenerative condition. Nonoperative management still is the most common treatment, but those patients who are disabled when this fails can expect improvement after surgery.

Prosthetic radial head components and proximal radial morphology: a mismatch.

A morphometric study of the proximal radius was performed with magnetic resonance imaging scans to measure the anatomic dimensions of the radial head and neck. These dimensions were then compared with the manufacturer's size specifications of commercially available titanium prosthetic radial head components to determine whether these designs adequately match the morphologic characteristics of the proximal radius. A cadaveric correlation was performed to validate the accuracy and reliability of measurements obtained from the magnetic resonance scans. The narrow intramedullary dimensions of the radial neck negated fitting of even the smallest available metallic prosthetic component stem in 18 (39%) of 46 scans reviewed (confidence interval 26% to 53%). Of the 31 male patients who underwent scanning, 4 (13%) would not be able to be fitted with a prosthetic component according to the manufacturer's technique guide (confidence interval 0% to 29%). Of the 15 female patients who underwent scanning, 14 (93%) would not able to be fitted with a prosthetic stem (confidence interval 70% to 99%). In those patients in whom the radial neck could accommodate a prosthetic stem (n = 26), there was ineffective restoration of proximal radial head length in all cases (100%, confidence interval 87% to 100%). The average shortening was 4 mm of proximal radial length (range 1 to 7 mm). Our findings reveal that the commercially available metallic radial head design may overestimate the dimensions of the radial neck. Inadequate sizing of radial head prostheses may lead to an inadvertent change in proximal radial length, with potentially adverse effects on elbow, forearm, and wrist mechanics. Newer designs taking into account these anatomic dimensions may lead to an improvement in function after reconstruction.

Current therapy in the management of heterotopic ossification of the elbow: a review with case studies.

Heterotopic ossification, or the appearance of ectopic bone in para-articular soft tissues after surgery, immobilization, or trauma, complicates the surgical and physiatric management of injured joints. The chief symptoms of heterotopic ossification are joint and muscle pain and a compromised range of motion. Current therapies for prevention or treatment of heterotopic ossification include surgery, physical therapy, radiation therapy, and medical management. Unlike heterotopic ossification of the hip, heterotopic ossification of the elbow has not been extensively investigated, leaving its optimal management ill-defined. To remedy this deficiency, we review risk factors, clinical anatomy, physical findings, proposed mechanisms, and current practice for treatment and prevention of heterotopic ossification. We then consider and draw conclusions from four cases of elbow injury treated at our institutions (three complicated by heterotopic ossification) in which treatment included surgery, radiation therapy, physical therapy, and medical therapy. We summarize our institutional practices and conclude with a call for a randomized clinical trial to better define optimal management of heterotopic ossification of the elbow.

The skeletally fixed knee hinge for the grossly unstable knee.

This study examined whether a skeletally fixed prefabricated knee hinge can provide the intact or unstable knee with normal motion through a specific arc of motion. Eight cadaveric knee specimens were used. The amount of motion mismatch between knee and hinge motion was evaluated at six different knee flexion angles. With all knee ligaments intact, addition of the hinge resulted in increasing amounts of joint compression with knee flexion. When all knee ligaments were cut, there was some degree of distraction with 0 degrees of knee flexion, which seemed to gradually decrease and become compressive at 80 degrees of flexion. These values were not statistically significant. In contrast, the mismatch between anterior and posterior tibial translation mismatch was statistically significant. With the ligaments intact, the addition of the hinge resulted in increased amounts of posterior tibial translation, which became significant at 80 degrees of flexion. Similarly, when the ligaments were cut with the hinge intact, there was an increasing amount of posterior tibial translation, which became significant at 60 degrees of flexion. There was also a significant amount of anterior tibial translation at 0 degrees in this group. These results indicate that the hinge allows only a limited range of motion that does not significantly alter tibial translation or joint compression or distraction. Whether this amount of motion is enough to improve the outcome of the grossly unstable knee is unknown. The use of a more sophisticated hinge system might accomplish a greater range of anatomic motion before significant mismatch occurs between hinge and knee motion.

Disorders of the forearm axis.

Forearm pronosupination is a complex, integrated activity that demands specialized function of all structures between the elbow and wrist. This article describes the forearm axis as a comprehensive concept to unify these relationships. The anatomy and biomechanics of the forearm axis are reviewed. Pathologies that affect the entire axis are summarized.

Fractures of the radial head and related instability and contracture of the forearm.

Displaced fractures of the radial head that require reduction or excision are often associated with longitudinal instability. Where possible (type II), these fractures should be stabilized with rigid internal fixation In cases in which the initial displacement reflects complete dissociation, supplemental stabilization and repair may be required. Particular attention must be paid to the posterolateral collateral ligament, the interosseous ligament of the forearm, and ligaments at the distal radioulnar joint.

Wide excision of the distal ulna: a multicenter case study.

Excision of the distal ulna to treat degenerative disease or instability has fallen into disfavor following reports of radioulnar impingement, carpal instability, and distal ulnar instability. Alternative procedures for reconstruction of the painful distal ulna have been developed to address these problems; the results have been generally favorable. When faced with distal ulnar reconstruction that has failed after multiple surgical procedures, or a distal ulnar neoplasm, the surgeon is left with few treatment options. Creation of a one-bone forearm, free fibular transfer, and allograft replacement have been attempted, with mixed outcomes. We report the results of 5 men and 7 women who underwent wide excision of the distal ulna, defined as surgical excision of 25% to 50% of the ulnar length. The diagnosis was failed distal radioulnar reconstruction or excision in 8 patients, osteomyelitis in 1, congenital pseudoarthrosis of the radius in 1, and neoplasm in 2. No soft tissue reconstruction was performed. Patients were examined at an average of 22 months after surgery for radiocarpal and radioulnar instability, functional outcome, pain relief, grip strength, and range of motion. Nine of the 12 procedures resulted in good or excellent results; 1 patient had a fair result after resection for osteosarcoma, and the procedure in 2 patients failed, requiring conversion to a one-bone forearm. Grip strength was restored to 75% of the normal side and range of motion was restored to 86% of the normal side. Wide excision of the distal ulna without soft tissue reconstruction is a simple and durable treatment of neoplasms of the distal ulna or salvage of the failed reconstruction of the distal radioulnar joint. We do not recommend its use in patients with incompetency or disruption of the interosseous membrane.

Adventitial stripping: a digit saving procedure in refractory Raynaud's phenomenon.

OBJECTIVE: To assess the efficacy and role of adventitial stripping (i.e., digital sympathectomy) in patients with severe digital ischemia secondary to refractory Raynaud's phenomenon (RP). METHODS: A retrospective chart review of 13 consecutive cases of adventitial stripping in 9 patients with severe secondary RP was performed, examining patient characteristics, previous therapeutic interventions, and postoperative outcomes. An illustrative case is presented. RESULTS: All identified patients had evidence of systemic disease. After adventitial stripping, sustained longterm improvement was achieved in all 13 ischemic digits, 8 of which showed amelioration of symptoms immediately after surgery. In 2 patients, sustained improvement was noted despite progressive ischemia in nonoperated digits. The mean followup time was 28 months (range 10 to 47). No postoperative complications were observed. Pre-operative sympathetic nerve blockade was performed in 12 of the cases, of which 10 showed no clinical response. Pathologic specimens revealed adventitial fibrosis that caused extrinsic compression of the digital arteries. CONCLUSION: Adventitial stripping of digital arteries is an extremely effective and safe option for patients with severe digital ischemia secondary to refractory RP. The efficacy of this procedure results not only from sympathetic denervation but also from decompression of the ischemic vessel through removal of a fibrotic and noncompliant adventitia. Because of the effects of this extrinsic vascular compression, lack of response to pre-operative sympathetic nerve blockade is not predictive of postoperative outcomes.

Dynamic skeletal fixation in the upper extremity.

Recent advances in the understanding of the biomechanics of the elbow and improvement in material designs have revolutionized the ability to treat difficult problems of the proximal interphalangeal and elbow joints. Dynamic skeletal fixation addresses the desire to allow an injured joint to heal, move, and remain stable simultaneously. In the past, such goals were achieved sequentially or in series. It is now possible to perform such tasks in parallel.

The utility of high-resolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist.

We performed a prospective study in order to assess the utility of high-resolution magnetic resonance imaging in the detection and specific localization of tears of the triangular fibrocartilage complex. Seventy-seven patients who had pain in the wrist were studied with use of a dedicated surface coil and three-dimensional gradient-recalled techniques with a field of view of eight centimeters and a slice thickness of one millimeter. The patients had pain on the ulnar side of the wrist, ligamentous instability, occult ganglia, or a combination of these. Magnetic resonance images were assessed for radial or ulnar avulsion, or both; central defects; degenerative intrasubstance changes; and complex tears of the triangular fibrocartilage complex. Partial tears were differentiated from complete tears. The findings on the magnetic resonance images were then compared with the arthroscopic findings. Fifty-seven of the fifty-nine tears that were suspected on magnetic resonance images were confirmed with arthroscopy; the two suspected tears that were not confirmed had been interpreted as small partial tears on the magnetic resonance images. With use of arthroscopy as the standard, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-seven of fifty-seven), a specificity of 90 per cent (eighteen of twenty), and an accuracy of 97 per cent (seventy-five of seventy-seven) for the detection of a tear (kappa = 0.93, p < 0.00001). Fifty-three of the fifty-seven tears were localized correctly with use of magnetic resonance imaging. With regard to the location of the tear, magnetic resonance imaging had a sensitivity of 100 per cent (fifty-three of fifty-three), a specificity of 75 per cent (eighteen of twenty-four), and an accuracy of 92 per cent (seventy-one of seventy-seven) (kappa = 0.9, p < 0.0001). We concluded that high-resolution magnetic resonance imaging permits accurate depiction and localization of tears of the triangular fibrocartilage complex. When the appropriate pulse sequence is used, magnetic resonance imaging is an accurate and effective method for the non-invasive evaluation of pain in the wrist.

Ligament reconstruction basal joint arthroplasty without tendon interposition.

The necessity of tendon interposition for the maintenance of joint space after basal joint resection arthroplasty with ligament reconstruction has not been established. A prospective, randomized study was performed. In Group I (nine patients), ligament reconstruction was performed to suspend the first metacarpal in addition to placement of a rolled tendon interposition to fill the void created by resection of the trapezium. In Group II (11 patients), ligament reconstruction alone was performed, with use of a Mitek suture anchor. No tendon interposition was performed. This allowed use of a more limited incision and shorter length of tendon graft. Average followup was 23 months. There was no difference between the two groups in range of motion of the thumb, grip strength, lateral pinch strength, the ability to perform activities of daily living, or subjective satisfaction with the procedure. Two- and three-point pinch strength was statistically significantly greater in Group II. Lateral radiographs of the basal joint at followup, at rest and with pinch, showed maintenance of the joint space, and no difference between the two groups. Tendon interposition is not necessary for maintenance of joint space after basal joint resection arthroplasty if ligament reconstruction is performed.

Posterolateral rotatory instability of the elbow: usefulness of MR imaging in diagnosis.

PURPOSE: To evaluate the efficacy of magnetic resonance (MR) imaging in the assessment of the normal and abnormal ulnar band of the lateral collateral ligament for diagnosis of posterolateral rotatory instability. MATERIALS AND METHODS: In nine symptomatic patients and nine asymptomatic subjects, MR imaging was performed with three-dimensional gradient-recalled and fast spin-echo sequences. The nine patients had clinical symptoms suggestive of subtle elbow instability. RESULTS: The components of the lateral collateral ligament were identified; tears of the ulnar band were noted in all symptomatic patients. The anterior fibers of the lateral collateral ligament, including the annular ligament, were intact. All symptomatic patients subsequently underwent surgical exploration and reconstruction. Positive clinical findings were demonstrated at examination performed while the patients were under anesthesia. All tears of the ulnar band were confirmed. CONCLUSION: With use of appropriate pulse sequences, MR imaging is an effective tool in the preoperative, noninvasive diagnosis of posterolateral rotatory instability.

Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor.

Thirty-six consecutive patients with 37 complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal (MP) joint were treated with primary repair using a miniature intraosseous suture anchor. Thirty patients were evaluated by clinical examination or by questionnaire at an average of 11 months after repair. Loss of interphalangeal joint motion averaged 15 degrees on the involved side versus the other side, while loss of MP joint motion averaged 10 degrees. There was no significant difference on stress testing measurements between repaired and nonrepaired thumbs. There were no instances of nerve injury, infection, device failure, or reoperation. The authors concluded that this is a safe and effective method for repair of complete tears of the ulnar collateral ligament of the thumb MP joint.

The use of frozen-allograft radial head replacement for treatment of established symptomatic proximal translation of the radius: preliminary experience in five cases.

Five patients with disabling symptoms related to proximal translation (> 1 cm) of the radius following radial head excision (Essex-Lopresti lesion) were treated with implantation of a frozen-allograft radial head prosthesis. Following restoration of neutral ulnar variance at the wrist, a size-matched frozen radial head allograft was implanted and secured to the proximal radius with internal fixation. In three patients, this was a two-stage procedure; radial length was restored gradually using an ilizarov external fixation device and the allograft was placed later. Patients were evaluated clinically and radiographically at a mean follow-up time of 3 years (range, 1-7 years). All patients had relief of wrist and elbow pain and were satisfied with the outcome of the operation. Forearm rotation improved by a mean of 37 degrees and wrist motion improved by a mean of 45 degrees. Forearm reconstruction with frozen radial head allograft implantation may be a beneficial method of treatment for this difficult problem.

Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve.

An anatomical study was performed to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. In ten cadaveric specimens, the radial nerve was found to cross the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. As it crossed the posterior aspect of the humerus in each specimen, the nerve had several branches to the lateral head of the triceps; however, no branches were found innervating the medial head of the triceps in the posterior aspect of any of the specimens. At the lateral aspect of the humerus, the nerve trifurcated into a branch to the medial head of the triceps, the lower lateral brachial cutaneous nerve, and the continuation of the radial nerve into the distal part of the upper arm and the forearm. Three operative approaches were performed in each specimen. The posterior triceps-splitting approach exposed an average of 15.4 +/- 0.8 centimeters of the humerus from the lateral epicondyle to the point at which the radial nerve crossed the posterior aspect of the humerus. For the second approach, the radial nerve was mobilized proximally to allow an additional six centimeters of the humeral diaphysis to be visualized. The third approach (the modified posterior approach) involved the identification of the radial nerve distally as it crossed the lateral aspect of the humerus, followed by reflection of both the lateral and the medial heads of the triceps medially. This exposure permitted visualization of 26.2 +/- 0.4 centimeters of the humeral diaphysis from the lateral epicondyle proximally. The results after use of the modified posterior approach in seven patients were also reviewed.

Cubital tunnel surgery. Complications and treatment of failures.

Cubital tunnel surgery should be considered a failure if patients have no relief of their symptoms of if the symptoms recur shortly after the surgery. Choice of treatment should be based on careful examination and evaluation of patient expectations, general medical condition, level of activity, and duration and severity of symptoms. Failure of the initial procedure may be the result of inadequate release, instability, subluxation, inadvertent creation of a new site of compression, and intraoperative nerve injury. Certain clinical manifestations specify the cause for failure. A positive Tinel's sign, for example, may indicate the exact location of persistent nerve compression. A palpable mobile mass on the medial aspect of the elbow is consistent with recurrent subluxation. Localized point tenderness along the course of the incision may indicate a neuroma secondary to injury to the medial antebrachial cutaneous nerve. In all cases, it is imperative that the surgeon be familiar with all the possible anatomic sources of compression as well as the variations in the ulnar nerve and the medial antebrachial cutaneous nerve. Once operative failure has been determined, efforts should be directed at completely releasing the nerve through external neurolysis, eliminating any mechanical stretch, and releasing any sites of compression or kinking. Some improvement should be expected if the surgeon thoroughly understands the anatomy, chooses the appropriate revision technique based on patient history, and adheres to the technical details of the chosen revision technique.