Role of Wrist Arthroscopy in the Management of Established Scaphoid Nonunion.

Introduction Patients with scaphoid nonunion and wrist pain may have a wide spectrum of potential concomitant pathologies that may be diagnosed and potentially managed arthroscopically. The aim of this study is to assess the usefulness of wrist arthroscopy in the assessment and treatment of scaphoid nonunion and any associated injuries. Materials and Methods We retrospectively reviewed 34 consecutive patients with established scaphoid nonunion between January 2006 and December 2012 who had undergone arthroscopic assessment. The average age of the patients was 40 years (range: 25-64), and all the patients had arthroscopic assessment of the wrist joint before definitive surgery. The patients with associated intra-articular problems, which could be addressed along with the scaphoid open reduction internal fixation (ORIF) and bone grafting (BG), had definite procedure in the same sitting. However, if the patients had major intra-articular pathology that needed change in the management plan, they had staged definitive treatment after discussing with them about the arthroscopic findings. Results Arthroscopic assessment of the 34 joints showed varying degrees of arthritis affecting radioscaphoid joint (41%) followed by injuries to the triangular fibrocartilage complex (TFCC) (35%), lunotriquetral ligament (LTL) tears (32%), and scapholunate ligament (SLL) injuries (26%). Concomitant procedures performed during the wrist arthroscopy included debridement of synovitis (62%), TFCC debridement (32%), loose body removal (17%), and DRUJ stabilization and TFCC repair (3%). Twenty-nine patients had arthroscopy and definitive procedure in the same sitting, and the remaining had staged or delayed definitive treatment. Conclusion Our study highlights the usefulness of wrist arthroscopy in assessment and management of the scaphoid nonunion and associated pathologies. Besides in 18% of our patients, the initial management plan changed after arthroscopy. Level of Evidence This is a Level IV study.

Delayed Reconstruction Following Incarceration of the Medial Epicondyle in the Elbow Joint: A Case Report and Review of the Literature.

CASE: Neglected medial epicondylar fractures with intra-articular incarceration are uncommon. At 6 weeks after an elbow dislocation, an 11-year-old child was referred to our unit with painless, restricted range of motion. Clinical assessment and radiographic imaging revealed an incarcerated medial epicondylar fragment in the ulnohumeral joint. We performed open reduction and internal fixation (ORIF) and transposed the ulnar nerve. The clinical and radiographic outcomes at the final follow-up were excellent. CONCLUSION: The management of neglected pediatric medial epicondylar fractures with intra-articular incarceration is challenging. Identifying the fractured fragment is essential. Although the outcome following excision is variable, children who have undergone ORIF with ulnar nerve transposition have regained full function, despite delayed reconstruction.

Elbow instability following lateral collateral ligament complex avulsion fracture and joint interposition: an uncommon presentation.

The lateral collateral ligament (LCL) complex of the elbow is a capsuloligamentous structure, critical for elbow stability. Though isolated ligamentous injuries have been reported in literature, there are no studies reporting avulsion fractures of the lateral ligamentous complex of the elbow with joint incarceration in a child. An 11-year-old boy presented to the emergency department after a fall from height, with pain and swelling to the lateral side of his left elbow. Radiographs established a fracture of the lateral condyle and CT imaging confirmed an avulsion of the lateral ligamentous complex, with fragments in the inferior radiocapitellar joint. Examination under anaesthesia revealed an unstable elbow with restricted extension, and the child underwent joint debridement and open reduction internal fixation of LCL complex with cannulated screws. At the final follow-up at 15 months, the child regained preinjury level of function.

Scapular spine stress fractures: To fix or not to fix, our experience in a patient with bilateral fractures and review of the literature.

We report a case of bilateral scapular spine stress fracture, treated conservatively on one side and operatively on the other side. Besides, we performed a literature review to establish management options. A 61-year-old right-handed gentleman came to our clinic with acute on chronic deterioration of shoulder pain and loss of arm function. Clinical assessment and investigations revealed long-standing bilateral rotator cuff tear and scapular spine stress fractures. The fracture on the right side united with conservative management for 2 months. However, his left side remained symptomatic with pain, abnormal mobility and no radiological evidence of union. The fracture progressed to union after fixation and bone grafting. At the final follow-up at 2 years, the patient was asymptomatic with regards to the fractures with Oxford Shoulder Score (OSS)-30 and Disabilities of the Arm, Shoulder and Hand (DASH)-30.8. Fracture union either by conservative or operative treatment is associated with good functional outcome and is supported by our review.

Management of heterotopic ossification and restricted forearm rotation after tension band wiring for olecranon fracture.

A 32-year-old lady presented to our clinic with persistent painful restriction of her dominant forearm movements for three months after tension band wiring of olecranon. She had full elbow flexion and extension; however, her forearm rotations were restricted and painful. Investigations revealed prominent tips of the wire, eroding the radial tuberosity with heterotopic ossification between the radius and ulna. As there was no synostosis, the patient had implant exit. During surgery, before implant removal, examination under anaesthesia revealed a mechanical block of the rotation beyond 30° on pronation and supination from neutral. However, after the removal of implant, the mechanical block eased off and with gentle manipulation, full pronation and supination were achieved. At the final follow-up at 6 months, the patient had full pain-free forearm rotation with regression of heterotopic ossification. Our case report highlights the importance of intra-operative assessment of wire tips at full supination and pronation, and in patients with restricted forearm rotation, CT scan may be needed to assess the position of the hardware is essential as it can progress to synostosis. In cases with prominent hardware, removal of the implant may suffice if performed before the development of synostosis.

Intraoperative Life Threatening Acute Lung Injury Due to Multiple Septic Pulmonary Emboli during Transpedicular Biopsy and Kyphoplasty.

A 55-year-old gentleman was presented to our clinic two months after a trivial fall with persistent pain, gibbus at the thoraco-lumbar junction and intact neurology. Radiological and laboratory investigations suggested osteoporotic fracture or metastasis. Due to unremitting pain, a plan was made to do transpedicular biopsy and kyphoplasty. Biopsy needles were inserted into both pedicles and an attempt at aspiration was made. Since the aspirate was dry, 5 to 6 mL of saline was injected through one needle and an attempt at aspiration was made through the other. Three-millilitres of sero-sanguineous material mixed with pus came out and kyphoplasty was deferred. After extubation, the patient developed severe bronchospasm and was transferred to the intensive care unit. Investigations confirmed multiple septic pulmonary emboli and the patient recovered completely after treatment. This report highlights that confirmation of the diagnosis is essential before performing any procedure that increases the intravertebral pressure and the place should have appropriate facilities to manage complications.

Extensor Pollicis Brevis tendon damage presenting as de Quervain's disease following kettlebell training.

Kettlebell exercises are more efficient for an athlete to increase his or her muscle strength. However it carries the risk of injury especially in the beginners. A 39 year old gentleman came to our clinic with radial sided wrist pain following kettlebell exercises. Clinically patient had swelling and tenderness over the tendons in the first dorsal wrist compartment, besides Finklesten test was positive. Patient had a decreased excursion of the thumb when compared to the opposite side. Ultrasound/MRI scan revealed asymmetric thickening of the 1st compartment extensors extending from the base of the thumb to the wrist joint. Besides injury to the Extensor Pollicis Brevis (EPB) tendon by repetitive impact from kettlebell, leading to its split was identified. Detailed history showed that the injury might be due to off-centre handle holding during triceps strengthening exercises. Our report stresses the fact that kettlebell users should be taught about problems of off-center handle holding to avoid wrist injuries. Also, in Kettlebell users with De Quervains disease clinical and radiological evaluation should be done before steroid injection as this might lead to complete tendon rupture.

Unstable trochanteric fractures in elderly osteoporotic patients: role of primary hemiarthroplasty.

OBJECTIVE: Unstable intertrochanteric fractures in osteoporotic patients are difficult to treat. Fixation failure often leads to prolonged morbidity and poor functional outcomes. The objective of the present study was to investigate primary replacement as a suitable option that could minimize complications in selected patients. METHODS: From January 2004 to March 2007, 28 elderly osteoporotic patients with unstable intertrochanteric fractures were included in this study. Their fractures were classified according to the AO/OTA classification (8 patients, 31A2.2; 17 patients, 31A2.3 and 3 patients, 31A3.3) and their osteoporosis was confirmed by bone densitometry. Hemiarthroplasty was performed in all patients and the outcomes analyzed using the Harris hip score system. RESULTS: Of the 28 patients, 19 were women and the mean age was 79 years (range, 52-95 years). At a mean follow up of 4.2 years (range, 3-6 years), there were 17 excellent, 7 good, 2 fair and 2 poor results according to the Harris hip score system. CONCLUSION: In elderly osteoporotic patients with unstable intertrochanteric fractures, hemiarthroplasty is a reliable alternative to internal fixation. The functional outcome has been encouraging and we suggest it as a method of treatment in this group of patients.

Role of intraoperative 3D C-arm-based navigation in percutaneous excision of osteoid osteoma of long bones in children.

Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. We report the successful percutaneous excision of OO in five patients (upper end of femur - 3, tibia - 2). All patients had a minimally invasive reflective array fixed to the same bone followed by registration of anatomy by Iso-C three-dimensional (3D) C-arm. A tool navigator was used to plan the keyhole incision then a sleeve was introduced which allowed the usage of burr and curette to remove the tumor. After excision, the 3D C-arm was again used intraoperatively to confirm the complete eradication of the nidus. Adequate material for histology was obtained in four patients that confirmed the diagnosis of OO. In one child postexcision scans were successful in identifying incomplete removal requiring further excision of the nidus. All patients achieved excellent pain relief and were asymptomatic at an average follow-up of 3.2 years. 3D C-arm-based navigation offers the advantage of excellent localization, percutaneous excision, and intraoperative confirmation of adequate excision.