Transverse divergent dislocation of the elbow.

A girl 6 years 5 months old sustained a rare transverse (mediolateral) divergent dislocation of the elbow and was treated by closed reduction. The arm was immobilized in a cast. Followup was 7 years 5 months. Five years after injury, the patient had recurrent popping on the lateral aspect of the injured elbow during active flexion from complete extension and tenderness on the anterior aspect of the radiohumeral joint. To determine the exact anatomic relation of the proximal radius and ulna to each other and to the distal humerus after transverse dislocation, a skeleton of the elbow was assembled in the dislocated position, and multiple radiographs and photographs were taken and compared with the radiographs of the patient's injured elbow. This showed that the ulna was displaced posteromedially, with the coronoid process impinged against the distal and medial portions of the trochlea, and that the radial head was displaced lateral to the capitellum, anterior and distal to the lateral epicondyle. The distal end of the humerus was caught by the radius and the ulna and was rotated anteriorly and laterally, primarily by the displaced coronoid process. Because of this rotation of the humerus, the lateral radiograph of the elbow gave the impression that the head of the radius was displaced posteriorly.

Reconstruction of the anterior cruciate ligament of the knee using a doubled tendon graft.

The anterior cruciate ligament of the knee was reconstructed in 14 patients using doubled semitendinosus tendon graft put through one hole in the femur and two separate holes in the tibia. This was done in an attempt to duplicate the anatomic insertion of the anterior cruciate ligament on the tibia, to increase the strength of the tendon graft, and to reconstruct the anterior and posterior bundles of the anterior cruciate ligament. The follow-up period ranged from two and one-half to five years (average, 3.6 years). Before surgery, all patients complained of varying degrees of pain. Four were not able to participate in sports, seven had pain on walking, and nine complained of recurrent swelling. Lachman's test was positive in 14 patients; anterior drawer test was 3+ in ten patients and 2+ in four patients; and pivot shift test was positive in 13 patients. Anteromedial instability of 1+ was present in five patients; combined straight, anteromedial, and posterolateral instability in four patients; and anterolateral in one patient. Ten patients sustained a tear of the medial meniscus, two of the medial and lateral menisci, and one of the lateral meniscus. Chondromalacia and degenerative changes of the knee were noted in nine patients. After operation, four patients complained of aching sensation during weather changes and two of aching in the patellar region after strenuous sports activities. The Lachman test was negative in 11 patients and was less than 1+ in three patients. The anterior drawer test was negative in four patients, trace in two patients, less than 1+ in five patients, and 1+ in three patients. The pivot shift test was negative in all patients. All patients were able to return to their previous occupations; eight patients were able to participate in recreational sports and one in intercollegiate soccer. Using a standard rating system, after operation 12 patients were rated as excellent or good and two as fair (+).

Correction of habitual limp.

Following surgery or injury to a lower extremity, a patient may have a persistent limp in spite of an uneventful recovery and normal findings on physical examination. It may be difficult for the patient to overcome this habitual limp. Such a limp can be successfully corrected by instructing the patient to walk with both knees stiff and to step down on the heel first. This resembles a military goose-step except that it is done gently and resembles normal gait. This method has been used successfully by the author with at least 600 patients during the past 15 years. It should not be taught to elderly patients with poor balance.

Reconstruction of the anterior cruciate ligament using free tendon graft.

Twenty-seven patients were treated with an intraarticular tendon graft reconstruction of the anterior cruciate ligament. The tendon of the extensor of the fifth toe was used in five patients and the tendon of the semi-tendinosus muscle used in 22 patients. Followup ranged from 2 to 9 years, averaging 5.4 years. Fifteen patients remained pain-free, nine complained of only occasional ache, and three had more severe discomfort. One of those patients ruptured the graft postoperatively. Twenty patients were able to return to recreational sports and three to competitive sports. All patients were able to return to their previous occupations. Nine patients had evidence of severe or moderately severe arthritic changes in the injured knee prior to surgery, and an additional five patients had chondromalacia or early arthritic changes. The severity of arthritic changes was directly related to the time interval between injury and reconstruction of the ligament and also to the severity of the injury. Patients with arthritic changes greatly benefited from reconstruction of the ligament. The stability of the reconstructed ligament did not change during the followup if integrity of other ligaments was preserved or reconstructed.

Reconstruction for chronic scapuloclavicular instability.

Seventeen young patients with chronic scapuloclavicular instability were treated with tendon graft reconstruction. Sixteen patients had sustained a Type III and one sustained a Type II injury according to Allman's classification (Allman, FL: Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg 49A: 774-784, 1967). Both the coracoclavicular ligaments and the ligaments of the acromioclavicular joint were reconstructed. The operation was performed an average of 7.6 months after injury. The followup was from 8 months to 18 years, averaging 5.1 years. After surgery, 12 patients returned to heavy or moderately heavy work and eight engaged in athletics. All patients regained normal motion and muscle strength, except for one patient with posttraumatic hemiplegia. None required further surgery. Followup x-ray films showed no instability or degenerative changes.

Correction of equinus deformity following midtarsal amputation by tibiotalar arthrodesis: a case report.

Transtarsal amputation in a 49-year-old man was unacceptible because of associated equinus deformity of the ankle and callus formation on the sole of the foot. The equinus deformity and callus formation were corrected by fusion of the ankle in 10 degrees of dorsiflexion and advancement of the talus and os calcis anteriorly. The operation produces a larger weight-bearing area than Syme's amputation, does not disturb the normal weight-bearing fat pad underneath the os calcis, and preserves the length of the extremity as well as the motion in the subastragalar joint.

Sports-related injuries in school-aged children.

Most studies of sports-related injuries have been investigations of specific injuries resulting from specific, organized sports at the high school, college, or professional level. This study documented all types of sports-related injuries received by all school-aged children in a midwestern community of 100,000 for a 1-year period. Public and private schools, community sports programs, hospital emergency rooms, the schools' accident insurance company, and local physicians provided initial accident reports. Injuries were sustained by 3% of all elementary school students, 7% of all junior high school (grades 7 and 8) students, and 11% of all high school students. Nonorganized sports and physical education classes each produced nearly twice as many injuries as organized sports. One-fifth of the injuries were considered serious and one-fourth of all injuries could have been avoided had nominal safety precautions been observed.

Relationship between trauma to the extremities and stomach motility.

Rate of emptying of the stomach before and after injury was studied by feeding dogs with barium and taking X-rays at regular intervals before and following injury. The injured extremity was not protected in the first group of dogs, and was protected by a cast or splint in the second group. The dogs in a third group were sedated with Nembutal. As compared to control the emptying of the stomach after trauma was markedly delayed or even stopped in the first group and was accelerated in the second group. It was very slow before and after trauma in the Nembutal group. The delay noted in the first group was not related to the time of trauma, but to the time of developing severe pain, swelling, and shock. Mechanical immobilization appeared to be the most important method of preventing the delay of emptying of the stomach after injury; sedation slowed down normal function of the stomach.

Late reconstruction of the ligaments following acromioclavicular separation.

Complete separation of the acromion from the clavicle in nine young patients was repaired by a new technique with use of a tendon graft. The operation was performed, on average, twenty-nine weeks after the injury. After surgery seven patients were enabled to engage in strenuous sports or construction work and the other two to return to daily activities with occasional heavy lifting.