Precision oblique osteotomy for shortening of the ulna.

The obstacles of prolonged healing time and technically demanding osteotomy and plate fixation in the performance of ulnar shortening osteotomies have been overcome by a precision system that includes a 45 degrees osteotomy and 2.7 mm interfragmentary lag screw. In 23 transverse osteotomies healing time averaged 21 weeks with one nonunion. In 17 precision oblique osteotomies healing time averaged a substantially shorter 11 weeks. Biomechanical data obtained from cadaveric testing comparing these two constructs demonstrated a structural stiffness that was clearly greater in torsion testing for the oblique osteotomy. No biomechanical difference was identified in the anteroposterior and lateral bending tests. The system permits the reliable performance of two parallel osteotomy cuts, allowing the removal of a precise amount of bone. The compression device and specialized plate permit easy coaptation of the osteotomy surfaces, which are locked into position by a precise 22 degrees interfragmentary lag screw. The surgical procedure is more quickly completed, and the frustration of this previously challenging procedure is now completely removed.

The history and evolution of percutaneous pinning of displaced distal radius fractures.

This article discusses the history and evolution of percutaneous pinning of displaced distal radial articular fractures. Six distinct methods are examined from an historical viewpoint, focusing on problems associated with each technique. The evolution of the Kapandji technique to include arum nuts and the Rayhack technique to include an alignment jig and pin guide with locking set screws is presented also.

Closed elbow dislocation and brachial artery damage.

Damage to the brachial artery associated with closed elbow dislocation but without accompanying fracture is rare. Only 25 cases have been reported to date. We present a case that responded well to brachial artery vein grafting, and review the literature on this subject. Operative repair is recommended in this uncommon complication of closed dislocation of the elbow.

Computed analyses of the pathomechanics of scaphoid waist nonunions.

The computed tomography scans of both the injured and the normal wrists of nine patients with a scaphoid nonunion of 5 to 120 months' duration were used to create three-dimensional computer models. When the computer images of the normal and the contralateral fractured scaphoids were superimposed, it was possible to calculate the volume of bone that was lost as a result of the injury and its failure to heal, as well as the angular relationship of the fracture components to one another. The amount of the scaphoid bone that was lost varied from 6% to 15% of bone volume and did not show a linear correlation with the duration of the nonunion. The configuration of the missing bone was consistent and exhibited a prismatic shape whose base is quadrilateral and faces palmarly. The proximal scaphoid fracture component is extended, radially deviated, and supinated in relation to its distal fracture component. The consistent fracture deformity and the configuration of the bony defect in the scaphoid waist nonunions should be helpful in the understanding and treatment of the condition.

Digital subtraction arthrography of the wrist.

Digital subtraction arthrography of the wrist was used to identify abnormalities in eighty-six (60 per cent) of 139 patients during a fifteen-month period. Multiple abnormalities were noted in thirty-four (25 per cent) of the wrists. The clinical signs and symptoms in the eighty-six wrists did not always correlate with the defects that were seen on the arthrograms. Three of five patients who had an isolated tear of the scapholunate ligament, six of thirteen who had an isolated tear of the lunotriquetral ligament, and seven of nineteen who had an isolated tear of the triangular fibrocartilage complex also had signs and symptoms on the opposite side of the wrist. Many of the lesions that were seen on arthrography may have been serendipitous, degenerative, or unrelated to a specific injury. There was a high prevalence of positive ulnar variance in patients who had at least one ulnar abnormality. Capsular tears, most often seen on the radiovolar aspect of the wrist, were best outlined by contrast medium injected into the radiocarpal joint. The arthroscopic findings differed from the arthrographic findings in five of the twenty patients in whom both studies were done. The three-compartment technique of injection is a valuable diagnostic tool. Injections of contrast medium into the distal radio-ulnar joint outlined five of thirteen tears of the triangular fibrocartilage complex that were not seen after injection into the radiocarpal joint. Of the eleven tears that were seen after injection into the radiocarpal joint, five were not seen when contrast medium was injected into the distal radio-ulnar joint.

Advanced imaging of the wrist.

In an effort to improve the radiologist's contribution to the evaluation of the painful wrist, the authors have studied the usefulness of a variety of imaging techniques. Preliminary results of these studies, including: 173 conventional CT, 80 3-D CT, 119 postarthrography CT, 138 multiple compartment digital subtraction arthrography and 55 MRI examinations, are reported, and technical aspects of the examinations are described.

Transulnar percutaneous pinning of displaced distal radial fractures: a preliminary report.

Difficulty in maintaining the reduction of displaced radial fractures has prompted the use of numerous techniques to address this problem. The purpose of this study was to determine if four or five 0.045-in Kirschner pins when placed percutaneously through the ulna into the radius could maintain the reduction of this unstable fracture configuration. A 15-month average follow-up of 14 patients, averaging 48 years old, included subjective patient responses and range-of-motion measurements of the forearm, wrist, and digits in addition to grip strength determinations. Analyses of the radial angle and radial height were made on the posteroanterior radiograph, and the articular inclination was assessed on the lateral radiograph. Overall results were 2 excellent and 12 good using the Scheck demerit system of evaluation. The advantages of this technique are as follows: Radial sensory nerves are avoided; use of a lightweight splint at 3 weeks promotes patient comfort and facilitates finger range-of motion exercises; percutaneous pins are easily removed in the office without anesthesia; and pin site scars are barely perceptible at follow-up in the majority of patients.

CT of the wrist for the evaluation of traumatic injuries.

Computed tomography (CT) of the wrist can help evaluate many types of posttraumatic injuries, particularly bony trauma. Most wrist fractures can be diagnosed with routine radiography, but problematic cases and complicated healing fractures can be difficult to evaluate with conventional radiography. CT provides improved contrast resolution and multiplanar imaging. The results of complex healing fractures and fusion procedures can be facilitated with CT. Even in the face of advanced osteoporosis CT can delineate bone edges and detect small areas of bony fusion. The degree of bone graft assimilation can be determined with CT. Unlike conventional radiography, metal fixation pins and cast material do not obviate diagnostic exams with CT. Certain posttraumatic complications such as distal radioulnar joint incongruity and hypertrophy of Lister's tubercle can be detected with axial CT images. Complicated cases of retained foreign bodies can be evaluated with CT. The high-contrast resolution of CT allows precise localization of foreign bodies and can define anatomic relationships to adjacent vital structures such as joints, tendons, and carpal tunnel. Postarthrography CT of the wrist is an investigational tool that permits direct visualization of the triangular fibrocartilage complex (TFCC). Complete and partial tears of the TFCC can be evaluated with postarthrography CT. Ulnar capsular tears and disruptions of interosseous ligaments can also be evaluated with this technique. The exact role of postarthrography CT of the wrist, however, is uncertain at this point. Three-dimensional CT is receiving increasing interest and may eventually help the understanding of wrist pathomechanics and kinematics. In summary, CT of the wrist can be instrumental in evaluating complicated posttraumatic injuries of the wrist and has certain advantages over routine radiography.

Work in progress: postarthrography computed tomography of the wrist: evaluation of the triangular fibrocartilage complex.

This report reviews a work in progress evaluating the use of postarthrography computed tomography (CT) of the wrist in assessing triangular fibrocartilage complex abnormalities. Twenty-two triangular fibrocartilage complex perforations in 119 patients were identified with both multiple compartment arthrography and postarthrography CT. To obtain a double contrast image of the triangular fibrocartilage complex, the postarthrography CT examinations were performed after multiple compartment arthrography and the injection of air into the radiocarpal compartment. The site of triangular fibrocartilage complex perforation could be identified (radial versus peripheral) as could degenerative changes and internal derangements such as chondrocalcinosis. We did not, however, find any information not provided by arthrography that would have changed the course of management. At this time there is no clinical role for postarthrography CT in the evaluation of triangular fibrocartilage complex derangements.

Posttraumatic ulnar translation of the carpus.

Ulnar translation of the carpus is a rare posttraumatic carpal instability pattern, in which the entire carpus is displaced ulnarward on the radioulnar surface. No previous formal reports of this problem have been located although it has been described in general discussions of wrist instability. Seven men and one woman were diagnosed with this condition although the diagnosis was delayed from 2 to 23 months, an average of 7.3 months. Three patients were treated surgically before diagnosis; the other five patients were treated conservatively before diagnosis. At the time of definitive diagnosis the radiographs showed an ulnar translation of the carpus, which was quantified on the radiographs in all eight patients by the method of Chamay. Four patients had an attempt to repair the radiolunate and radiocapitate ligaments. One patient had a ligamentous augmentation of the radiocapitate ligament complex. Two patients had ligamentous repairs of a scapholunate dissociation; one of these had simultaneous radiocarpal ligamentous augmentation. The eighth patient had a radiolunate arthrodesis. Follow-up averaged 32 months. Three patients had formal wrist arthrodeses at 10, 13, and 26 months after initial ligamentous repair, which were considered treatment failures. In the remaining five patients, four had partial recurrent ulnar shift, which was seen radiographically. Of these, three patients rated the result as good, with near normal strength and returned to full activities while two obtained fair results, with minimal pain but decreased range of motion and decreased strength. One patient has shown progressive degenerative radiocarpal changes and may become a candidate for a limited or formal wrist arthrodesis.

Scaphoid orientation and location from computed, three-dimensional carpal models.

Subtle subluxations within the carpus are often difficult to diagnose. Carpal orientation and location can now be quantified by mathematical analysis of computed, three-dimensional models produced from serial CT scans. The technique and its application in the analysis of scaphoid subluxation are described.

A strain recording model: analysis of transverse osteotomy fixation in small bones.

Many current experimental testing procedures are cumbersome when applied to osteotomies of small bones and are complicated by the need for in-depth analyses of data derived from various specimens tested to failure. This strain recording model minimizes these factors. Various forms of internal fixation may be serially tested on the same specimen with this system because constructs are not tested to failure but rather within the elastic range of each specimen. Sophistication in the form of strain recorded as a function of time allows the comparison of various fixation techniques. Fixation techniques applied to a transverse osteotomy and subjected to controlled flexion loading in a single plane have been evaluated. The study demonstrates the superiority of tension bands (wires) placed through holes immediately subjacent to the tension cortex in comparison with wires that fix the components through holes in the neutral longitudinal axis. In addition, for any given time, the strain generated by a single-looped tension band (wire) is greater than that of a figure-of-eight tension band (wire). Both types of tension bands afford superior stability experimentally, compared to conventional crossed Kirschner wire fixation of transverse osteotomies.

The erythrocyte sedimentation rate in orthopaedic patients.

The ESR, a sensitive measure of the inflammatory response, is elevated in 90% of patients who have serious orthopedic infections, e.g., discitis, septic arthritis, and hematogenous osteomyelitis. In most cases, it is sufficient to distinguish these entities from the less serious disease states, i.e., transient synovitis. After major surgical operations or extensive trauma, the ESR often increases to high levels and, if sepsis does not supervene, it returns to normal within six months. Outpatient determination of the ESR, although useless in the early detection of malignancy, is valuable in detecting inflammatory arthridities and major sepsis.