Glenoid labrum ossification and mechanical restriction of joint motion: extraosseous manifestations of melorheostosis.

We report a case of a 47-year-old man who presented with progressive loss of motion and pain in the right shoulder. Radiographs of the shoulder demonstrated dense ossification in the glenoid and humeral head with extension into the periarticular soft tissues. CT and MRI scans confirmed the radiographic findings and also revealed ossification of the glenoid labrum. A radiographic diagnosis of melorheostosis, an uncommon benign sclerosing bone dysplasia, was made. Because of the patient's severe symptomatology, he underwent total shoulder arthroplasty. Histological analysis of the resected masses was consistent with melorheostosis with a few areas covered by a cartilage cap. This case illustrates several uncommon but important features of melorheostosis, including mechanical obstruction of joint motion requiring joint replacement, ossification of the glenoid labrum, and cartilage-covering portions of the intra-articular masses, not to be confused with cartilage-producing tumors.

Injuries about the distal ulna in children.

This article examines several types of injuries about the distal ulna that appear in children. Ulnar styloid fractures are relatively common and tend not to have the deforming potential of Salter-Harris-type injuries. Physeal injuries with their potential for long-term growth impairment and functional limitation are potentially the most serious. Chronic stress injuries at the distal ulna, as seen in competitive gymnasts, and chronic late disruption of the distal radio-ulnar joint are also discussed.

Shoulder impingement/instability overlap syndrome.

Impingement syndrome is one of the most common shoulder problems seen by the orthopedist. Multidirectional instability is less common but can present with impingement symptoms. Patients having impingement symptoms due to multidirectional instability have a syndrome called "impingement/instability overlap." The purpose of this study is to retrospectively review 50 consecutive patients with a condition we have coined "impingement/instability overlap" syndrome. We discuss the criteria, by history and by physical examination, for inclusion in this category and the results of treatment. Our study shows that when the primary cause (instability) is treated with rehabilitation and/or surgery, the secondary symptoms, impingement and pain, can be alleviated. Conversely, if subacromial decompression is done to treat the secondary impingement, the primary symptoms, instability and pain, persist. Instability should be considered the primary etiology in any patient having impingement symptoms, especially in the younger patient (< 35 years old). Rehabilitative and surgical treatment should address the pathologic instability.

Splint immobilization of gamekeeper's thumb.

Thirty-nine patients diagnosed with 40 acute complete ruptures of the ulnar collateral ligament of the thumb metacarpophalangeal joint were treated primarily with thumb spica splint immobilization. Duration of splinting ranged from 8 to 12 weeks. Thirty-four of these injuries (85%) followed for 1 to 5 years (average 2.4 years) healed without significant instability, arthrosis, pain, or stiffness (range of motion within 80% of the contralateral hand). Six ruptures (15%) demonstrated persistent instability and pain at 12 weeks and were treated with surgical reconstruction. Currently accepted guidelines for surgical intervention as primary treatment for ligamentous disruption at the thumb metacarpophalangeal joint may need revision. This study suggests that splint immobilization is an effective primary treatment modality. The minority of patients who demonstrate persistent laxity can be successfully treated surgically with excellent results.

Non-neoplastic tumors of the hand and upper extremity.

A variety of non-neoplastic, tumor-like conditions exist in the upper extremity. Some are common, others rare. Careful history, physical diagnosis, and a variety of imaging modalities can be helpful in arriving at an accurate diagnosis and developing a successful treatment plan for this group of lesions.

Biomechanical and clinical evaluation of the epitenon-first technique of flexor tendon repair.

Thirteen matched pairs of canine flexor tendons were repaired using both the Epitenon-first and the modified Kessler with an epitendinous running suture. These were then tested to failure with a longitudinal force in an Instron test machine. Human cadaver flexor digitorum profundus tendons were used to determine the cross sectional area of the tendon that is displaced by suture material of the Kessler repair and Epitenon-first core suture. Results of biomechanical testing revealed the epitenon-first technique to be 22% stronger than the modified Kessler technique. Comparison of tendon repair cross sectional contact areas by digital scanning of surface photomicrographs demonstrated 20% of the surface area of the repair is occupied by the knot of the modified Kessler technique, while the core suture of the epitenon-first repair consumed only 2.6% of the cross sectional area. These findings correlate with our clinical results of 26 zone II flexor tendon repairs in 18 patients repaired with the epitenon-first technique over a 4-year period. Of these, there has been one rupture and no repeat operations for lysis of adhesions.

Digital lengthening using the callotasis technique.

A series of 14 lengthenings for congenital and posttraumatic digital deficiency has been carried out in a single stage utilizing individual, half-frame design, digital lengthening devices. These devices have afforded individual digital stability without need for additional external support and have provided between 2.0 cm and 3.5 cm lengthening per digit. In only one case was additional bone grafting necessary and in all cases the projected goal of lengthening was achieved. A slow rate of lengthening (0.25 mm in four daily increments) was associated with a minimal amount of pain, patients were able to utilize their hand for function during the lengthening period, and, in cases where physeal plates have remained open, continued growth has been experienced in the follow-up period.

Reconstructive strategies for radioulnar dissociation: a biomechanical study.

Radial head fracture combined with disruption of the soft-tissue restraints to proximal radial migration is defined as radioulnar dissociation. This injury often involves irreparable radial head fracture. When excised, management has emphasized the use of silicone implants to prevent proximal migration. However, concerns regarding silicone use led to the search for reconstructive alternatives. The purpose of this study was to compare reconstructive methods for radioulnar dissociation. Biomechanical testing to measure radial displacements under physiologic loads was performed on fresh-frozen cadavers after radial head resection. The central interosseous membrane (IOM) was disrupted to simulate radioulnar dissociation. This was followed by an orderly reconstructive sequence including radial head replacement with both silicone and titanium implants as well as a newly described flexible IOM reconstruction. Calculated stiffness values were used for comparison. Silicone implants provided no statistical improvement in forearm stiffness compared with the disrupted membrane state. Significant improvements were achieved with titanium implants and flexible IOM reconstruction, which restored stiffness to 89% and 94% of normal, respectively. No statistical differences were identified between these successful methods. Titanium implants combined with flexible reconstruction increased stiffness to 145% of normal. Further doubt is cast on the role of silicone implants in the management of radioulnar dissociation. Titanium implants and flexible IOM reconstruction appear to be wiser reconstructive choices.

Compression arthrodesis of the small joints of the hand.

A number of techniques for achieving small joint arthrodesis in the hand combine various forms of internal fixation with external cast or splint immobilization. Rates of arthrodesis in most cases are quite high. However, the prolonged period of adjacent joint immobilization from casting can extend rehabilitation time and limit hand function during healing. Compression arthrodesis has been used effectively in a number of larger joints, such as the knee and ankle. Miniaturization of existing external fixation compression devices now enables the application of this principle to the small joints of the hand. A series of 20 metacarpophalangeal and interphalangeal joints underwent arthrodesis in which a miniature external fixation/compression frame was used. Nineteen of 20 joints demonstrated complete primary arthrodesis within 6 weeks; one fibrous union developed in a distal interphalangeal joint and no postoperative deformities occurred. Complete stabilization was provided by the fixator, thus allowing immediate postoperative adjacent joint function.

Complications and problems in the management of distal radius fractures.

Despite the best of treatments, problems and complications may be inherent in the fracture, depending on the nature of its severity. For that reason, patients should be followed for a minimum of 2 years after injury and treatment to assess the result and rule out a degenerative processes. A careful, thoughtful analysis at the time of presentation using a descriptive classification system that provides guidance for therapeutic intervention followed by meticulous execution of the mode of treatment employed, regular follow-up care, and rehabilitation will provide the surgeon with a means to treat these common yet vexing problems in an effective way while minimizing complications.

Digital lengthening. With emphasis on distraction osteogenesis in the upper limb.

Digital lengthening, commonly practiced for hand digits of segments, seldom for those of the foot, has been much enhanced by new applications of old techniques and some surprising physiologic responses to those techniques.

Arteriovenous reversal for limb salvage in unreconstructible upper extremity arterial occlusive disease.

PURPOSE: Peripheral vascular disease of the upper extremity as a result of atherosclerotic disease or systemic vascular disorders presents a difficult management problem to the vascular surgeon. When extensive distal disease is present bypass procedures with standard arterial reconstruction techniques may not be possible. The use of retrograde perfusion to deliver oxygenated blood to the capillary bed by means of a normal venous system is not new. Flow reversal has been attempted in the myocardial, cerebral, and distal extremity circulations. Arteriovenous reversal (AVR) has been described for limb salvage in patients with upper extremity ischemia, with variable results. METHODS: We performed six AVR procedures on five patients with diffuse distal arterial disease and limb-threatening upper extremity ischemia. Two patients had insulin-dependent diabetes, one had systemic lupus erythematosus (two extremities), one had rheumatoid arthritis with vasculitis, and the remaining patient had CRST (calcinosis, Raynaud's disease, sclerodactyly, telangiectasia) syndrome. The two patients with diabetes had systemic manifestations of atherosclerotic vascular disease and lower extremity ischemia; the remaining three patients had no evidence of atherosclerosis. In all patients the AVR was performed at the most distal site of nondiseased artery. RESULTS: Limb salvage was obtained in all cases; one patient had a healed minor digital amputation, and another patient had a healed major amputation. Clinical improvement with resolution of pain was achieved in five of six cases. The remaining patient had a significant diabetic neuropathy that was believed to contribute to her persistent pain. CONCLUSIONS: In patients with severe upper extremity ischemia not amenable to standard revascularization techniques, AVR should be considered to provide limb salvage and maximize hand function.

External fixation of distal radius fractures. Indications and technical principles.

External fixation of unstable intra-articular fractures of the distal radius has become an effective tool in the management of these difficult injuries. Careful assessment of the fracture pattern, appropriate patient selection, meticulous surgical technique, the appropriate choice of fixation device and pins, recognition of the need for augmentation with limited internal fixation or bone grafting, and aggressive postoperative rehabilitation provide the foundation for successful management of these fractures while minimizing complications. The surgeon must remember that the pin-bone interface is the link between the patient and the fixator. He or she must ensure a stable environment for this interface by providing a clean, tight purchase of the pin in bone with minimal damage to the bone and its surrounding soft tissues at the time of operation. Postoperatively, the surgeon must convey to the patient the importance of maintaining a healthy environment for this pin-bone interface. An appropriately chosen external fixation device can be expected to provide overall stability while maintaining length as well as angular and rotational alignment. However, it cannot be expected to provide precise small fragment control and restoration of articular congruity. This must be achieved by precise reduction and limited internal fixation using Kirschner wires while prevention of late collapse is afforded by subarticular bone grafting of the metaphyseal defect. Adherence to these principles should provide a satisfactory outcome with a significant reduction in the rate of complications when external fixation is used for the management of complex fractures of the distal radius.

Sonography of the shoulder in patients with tears of the rotator cuff: accuracy and value for selecting surgical options.

OBJECTIVE: The management of patients with signs and symptoms referable to the rotator cuff depends on the presence of cuff injury and the size of the tear. Treatment options include conservative nonsurgical management for patients with an intact or partially torn cuff, arthroscopic decompression of the coracoacromial space for those not responding to nonsurgical management, and a range of surgical techniques to repair full-thickness tears. This study was designed to determine whether sonographic evaluation with classification of the extent of cuff injury is accurate for purposes of treatment planning. SUBJECTS AND METHODS: Preoperative sonography of the rotator cuff was performed on 225 patients, and findings were classified into intact, partial tear, small full-thickness tear, large full-thickness tear, and massive tear groups. Surgical correlation with the predicted sonographic classification was provided by arthroscopic inspection or open surgery. RESULTS: The sonographic findings were surgically confirmed for 206 (92%) of the 225 patients. More extensive cuff injury was encountered during surgery than had been predicted sonographically in 11 patients (5%); less extensive injury than predicted was found during surgery in eight patients (4%). CONCLUSION: Our results show a high correlation between the sonographic classification of rotator cuff injury and the surgical findings. The selection of appropriate treatment programs can be reliably based on the sonographic classification.

The figure-of-eight splint for proximal interphalangeal joint volar plate injuries.

Volar plate disruption of the proximal interphalangeal (PIP) joint is a common hand injury. Management of this injury must provide stability and motion to avoid disabling instability or stiffness. In this study, 40 patients with closed PIP joint volar plate injuries were treated with the figure-of-eight splint, a custom made, thermoplastic splint that allows protected joint motion. At two-year follow-up, 95% of these patients experienced good or excellent results. The figure-of-eight splint offers a simple and effective method of treatment for volar plate injuries of the PIP joint.

Autogenous bone marrow and allograft replacement of bone defects in the hand and upper extremities.

The posterior iliac crest has been shown to be an area extremely rich in red active marrow and it therefore provides a source of cells with osteoinductive and osteogenic potential. Concentration of these cells in the presence of routine bone graft enhances local healing of osseous defects and remodeling of graft into healthy bone, even in conditions where bone healing has been noted to be delayed and/or difficult. In a group of 29 patients there were no cases of adverse reactions to bone marrow aspiration or autogenous transplantation. Twenty-five of the 29 patients (86%) showed osseous union by 3 months postsurgery, while 28 of the 29 patients (96%) had complete incorporation at 6 months.

Augmented external fixation of unstable distal radius fractures.

The technique of "augmentation" of external fixation employs the use of percutaneous Kirschner wires to secure the radial styloid fragment as a lateral buttress, elevate and fix in place the depressed lunate fossa fragment, and, when necessary, add support to the elevated articular surface by means of subarticular bone grafting. A series of 51 cases of comminuted, unstable intraarticular distal radius fractures has been managed using this technique. Detailed evaluation has demonstrated precise articular reconstitution with an overall satisfactory result rate of 92%.

Callotasis lengthening in the upper extremity: indications, techniques, and pitfalls.

Bone lengthening through callotasis has been performed in 12 bones of the upper extremity in eight patients. Diagnoses included congenital amputations, phocomelia, radial agenesis, traumatic amputations, and infected fracture with bone loss. Nine of the 12 procedures resulted in complete consolidation of the transport gap with new bone without need for bone graft. One patient died of unrelated illness before completion of treatment but demonstrated early consolidation of the gap. In two cases bone graft was required. Complications included one superficial pin tract infection and one case of premature cessation of lengthening because of hand deviation. Early experience with this technique indicates that it is effective in the management of bone defects in the upper extremity. It appears that in most cases a half-frame lengthening device, rather than a more complex circular frame, can be used in the non-weight-bearing upper extremity. Adequate control of the distal segment, appropriate choice of location for corticotomy, and gentle handling of the bone and periosteum can improve results and minimize complications.

External fixator pin insertion techniques: biomechanical analysis and clinical relevance.

A series of identically matched pairs of fresh-frozen canine femora (approximating human radii in size and dimension) were used to mechanically compare pull-out strength between 4 mm predrilled, self-tapping, half-pins and 4 mm self-drilling, self-tapping half-pins with drill bit-like cutting flutes. A second biomechanical and videotape analysis was done comparing the differences of pin insertion by power versus hand drilling. Results indicated a mean 22% reduction in bone purchase of self-drilling, self-tapping pins compared with that of predrilled pins and a marked increase in depth of insertion required of the self-drilling pins for comparable pin purchase (10 mm). It was also observed that a visible "wobble factor" exists, which tends to weaken the pin-bone interface when hand drilling is performed.