Complications of smooth pin fixation of fractures and dislocations in the hand and wrist.

A retrospective review of patients treated with internal fixation of fractures or dislocations of the hand or wrist over a four-year period was undertaken to determine the complication rates of pin fixation for stabilization of these injuries. One hundred thirty-seven patients who received 422 pins were studied. All pins were unthreaded, measured 0.035-0.069 inches (0.9-1.8 mm) in diameter, were placed with a power drill, and were left protruding through the skin. The mean time that pins were left in place was 6.5 weeks, (range, two days to 24 weeks). Minimum follow-up time was 43 days after pin removal. Thirty-four complications occurred in 24 patients, and the overall complication rate was 18%. Forty-five of the 422 pins were involved (11%). Complications included infections in ten patients (7%), pin loosening without infection in six (4%), loss of reduction in six (4%), symptomatic nonunion in six (4%), impaled flexor tendon in two (2%), asymptomatic pseudarthrosis in one (1%), pin migration in one (1%), median nerve injury in one (1%), and radial artery injury in one (1%). Osteomyelitis developed in two of the patients with infections. Pin tract infection occurred at a mean time of ten weeks and aseptic loosening at a mean time of eight weeks. The frequent complication rates emphasize the need for meticulous pin placement, adequate intraoperative evaluation of pin position, and satisfactory patient compliance. Despite the frequency of these complications, serious permanent sequelae did not occur in most patients.

The dorsal branch of the ulnar nerve: an anatomic study.

The dorsal branch of the ulnar nerve was dissected in 24 cadavers. The nerve arose from the medial aspect of the ulnar nerve at an average distance of 6.4 centimeters from the distal aspect of the head of the ulna and 8.3 centimeters from the proximal border of the pisiform. Its mean diameter at origin was 2.4 millimeters. The nerve passed dorsal to the flexor carpi ulnaris and pierced the deep fascia. It became subcutaneous on the medial aspect of the forearm at a mean distance of 5.0 centimeters from the proximal edge of the pisiform. The nerve gave an average of five branches with diameters between 0.7 and 2.2 millimeters. A better understanding of the anatomy of this nerve may help prevent nerve injury during surgical procedures, and can help in locating the nerve for repair of lacerations or administration of local anesthetics for regional nerve blocks.

Wrist Pain in a Rugby Player.

A group of experts from the University of California, San Diego, School of Medicine, met to discuss a case. This case conference is part of a series featuring a variety of sports medicine topics.

Effect of heparinized irrigating solutions on patency of experimental microvascular anastomoses.

The effect of five different irrigating solutions on patency of four different types of microvascular anastomoses was studied. The solutions used were lactated Ringer's without heparin and four lactated Ringer's solutions with varying concentrations of heparin ranging from 10,000 units/liter to 100,000 units/liter. These were tested on four different anastomotic models in the rat: 1) end-to-end femoral arterial anastomosis; 2) end-to-side arterial bypass graft; 3) end-to-end venous anastomosis; and 4) end-to-side venous bypass graft. There were statistically significant differences in patency rates among the solutions only in the end-to-end venous anastomosis group. In these, significantly higher patency was achieved with heparinized lactated Ringer's solution at 20,000 units/liter. The use of higher concentrations of heparin in these solutions resulted in decreasing patency rates and appears to be contraindicated.

The triple-injection wrist arthrogram.

The last 100 patients to have wrist arthrography at our institution had, in addition to the standard radiocarpal joint injection, injections into the distal radioulnar joint and midcarpal joint. Seventy-seven of the 100 patients had abnormal arthrograms. In 29 cases abnormalities not identified by the radiocarpal joint injection were demonstrated either by the distal radioulnar joint or the midcarpal joint injection. In 38 patients abnormalities shown by radiocarpal joint injection were not demonstrable by the other two injections. Seven detachments of the triangular fibrocartilage complex from the ulnar styloid could be demonstrated only by the distal radioulnar joint injection. The midcarpal joint injection was far more useful than the radiocarpal joint injection in the evaluation of radiocarpal joint-midcarpal joint communications. All three injections appear to be necessary for a complete arthrographic evaluation.

Vascularized bone transfer: evaluation of viability by postoperative bone scan.

Postoperative assessment of the viability of vascularized bone transfer was done in 23 patients by using radionuclide imaging within the first postoperative week. Follow-up ranged from six to 45 months. The results of bone scans in the region of the vascularized bone transfer were positive in 16 patients. Of these, over 60 percent went on to uncomplicated union and a successful clinical outcome, with no frank failures. The results of scans were negative or equivocal in seven patients. Only 1 of these went on to uncomplicated healing and two cases (almost 30 percent) resulted in frank failure, necessitating removal of the transferred bone. Radionuclide imaging in the first postoperative week after vascularized bone transfer appears to be a useful monitor and prognostic indicator of the subsequent clinical course.

Pigmented villonodular synovitis of the wrist invading bone--report of a case.

Pigmented villonodular synovitis of the wrist joint invading adjacent bones rarely occurs. A case in which synovitis invaded the carpal and metacarpal bones at the ulnar aspect of the wrist is described. The invasion of multiple bones by the tumor and its histologic hypercellularity in this case caused concern because of its aggressive behavior. However, review of the literature on pigmented villonodular synovitis arising at the wrist and invading adjacent bones and follow-up of our patient confirmed its benign character.