Femoral neck stress fractures and metabolic bone disease.

OBJECTIVE: To determine whether metabolic bone disease plays a role in the cause of femoral neck stress fractures. STUDY DESIGN: Twenty-three patients with femoral neck stress fractures were enrolled prospectively in the study. Examination included computed tomography bone densitometry, trace mineral analysis, and histomorphometric analysis of the iliac crest in thirteen patients who underwent surgical treatment of their stress fractures. A control group of fifteen patients undergoing iliac crest bone grafting for scaphoid nonunions underwent similar examinations. SETTING: Tertiary military medical center. RESULTS: Patients with femoral neck stress fractures had lower bone mineral density than did control patients (p = 0.010), but no trace mineral deficiencies or consistent histomorphometric differences were noted. CONCLUSIONS: Bone mineral density is decreased in patients with femoral neck stress fractures. Despite observations of decreased bone mineral density in the stress fracture group, osteoporosis, as determined by histomorphometry, is not a consistent finding.

Subacute scaphoid fractures. A closer look at closed treatment.

Twenty-three subacute scaphoid fractures were retrospectively reviewed to determine the efficacy of nonoperative treatment. All of the patients sought medical attention between 4 weeks and 6 months after injury, and their fractures were classified according to location and stability. Nineteen fractures were observed to radiographic union or until closed treatment was abandoned; four patients were lost to followup. Nine of 10 stable subacute middle-third scaphoid fractures healed with cast immobilization in an average of 19 weeks (range, 11 to 38), and these were compared with a randomly selected group of acute middle-third fractures that healed in an average of 10 weeks (range, 6 to 13). Five of six unstable subacute middle-third fractures healed in an average of 20 weeks. One of these had a symptomatic humpback deformity treated by cheilectomy. Of three subacute proximal-third fractures, only one healed after 29 weeks of closed treatment. This study demonstrates that stable subacute middle-third scaphoid fractures will heal with cast treatment but may take twice as long to do so as stable acute middle-third fractures. Unstable subacute middle-third scaphoid fractures and subacute proximal-third fractures appear less likely to heal with closed treatment.

Acute median neuropathy after wrist trauma. The role of emergent carpal tunnel release.

Ten cases of acute carpal tunnel syndrome (ACTS) and six cases of nerve contusion were identified in patients with acute median neuropathy associated with blunt wrist trauma. The patients with ACTS initially had normal sensation and subsequently developed objective sensory loss (2-point discrimination greater than 15 mm) in the median nerve distribution associated with severe wrist pain. Patients with nerve contusion injuries had immediate sensory loss and symptoms were nonprogressive. Wick catheter measurements of the carpal canal pressure were used in seven patients to help distinguish ACTS (pressure greater than 40 mm Hg) from nerve contusion. The interstitial carpal tunnel pressure was elevated an average of 52 mm Hg in four of five patients with ACTS but was normal in two patients with nerve contusion. Four of five patients who underwent carpal tunnel release within 40 hours of the onset of numbness had normal 2-point discrimination within 96 hours. The results of this study and review of the literature reflect the urgency of carpal tunnel release in ACTS. Neuropathy, secondary to nerve contusion without coexisting ACTS, may be treated initially by observation. Acute carpal tunnel syndrome must be distinguished from nerve contusion as a cause of acute posttraumatic median neuropathy.

Multifocal osteonecrosis after short-term high-dose corticosteroid therapy. A case report.

Osteonecrosis is a common sequela of long-term steroid therapy. This paper presents the only case of multifocal osteonecrosis to occur after a short-term course of methylprednisolone for treatment of septic shock. Two years after receiving a two-week course of corticosteroid treatment, the patient developed pain in his right and left shoulders and left hip. Roentgenograms and magnetic resonance imaging revealed changes consistent with osteonecrosis of both humeral heads and the femoral head. The patient failed to respond to conservative treatment and eventually was treated with bipolar hip replacement.

Pediatric update #10. Treatment of displaced supracondylar fractures of the humerus in children by closed reduction and percutaneous pinning.

In a retrospective study of 25 displaced supracondylar fractures of the humerus in children, treatment by closed reduction and percutaneous pin fixation was reviewed. Follow-up averaged 16 months. Loss of elbow motion and carrying angle were graded according to Flynn's criteria. Twenty-two patients' results were rated excellent, two were good, none was fair, and one was poor. There were no complications reported. Comparison of the values of Baumann's angle obtained from intraoperative, postreduction roentgenograms with those of the opposite, normal elbows predicted the final carrying angles within two degrees in 14 of 17 cases and within five degrees in all 17 cases where such comparison was possible. We conclude that this technique is safe and effective and recommend the use of Baumann's angle as a standard to judge the quality of reduction.

Acute carpal tunnel syndrome secondary to septic arthritis of the wrist.

A case of acute carpal tunnel syndrome secondary to septic arthritis of the wrist is reported. Treatment consisted of carpal tunnel release, incision and drainage of the wrist joint, intravenous injection of antibiotics, and delayed primary closure. The infection resolved and median nerve function promptly returned to normal. We believe this is the first report of septic arthritis of the wrist as a cause of acute carpal tunnel syndrome.

The natural history of scaphoid non-union.

We reviewed the clinical and roentgenographic findings of forty-seven non-unions of a fracture of the scaphoid in forty-six symptomatic patients in order to assess the incidence and severity of degenerative changes of the wrist. The duration of non-union ranged from five to fifty-three years. Three roentgenographic patterns were seen: twenty-three lesions had sclerosis, cyst formation, or resorptive changes confined to the scaphoid bone (Group I); fourteen had radioscaphoid arthritis (Group II); and ten had generalized arthritis of the wrist (Group III). The duration of Group-I non-unions averaged 8.2 years; Group-II, 17.0 years; and Group-III non-unions, 31.6 years. Fracture displacement and carpal instability correlated with the severity of degenerative changes. Lunate dorsiflexion of 10 degrees or more was a useful guide to carpal instability. Few of the forty-seven non-unions were undisplaced, stable, or free of arthritis after ten years. Based on the high probability of arthritis, we recommend that all displaced ununited scaphoid fractures be reduced and grafted, regardless of symptoms, before degenerative changes occur. Asymptomatic patients with an undisplaced, stable non-union should be advised of the possibility of late degenerative changes.

Kienböck's disease--update on silicone replacement arthroplasty.

In a previous paper, early lunate silicone replacement arthroplasty (SRA) for Kienböck's disease was advocated because of poor results obtained in stage III disease. Since then, an additional 16 patients have been operated on. Thirteen had stage III disease, and 12 underwent successful SRA. This result is attributed to the modification in anatomical configuration and the improvement in the physical characteristics of the new high-performance silicone lunate implant. Because SRA gives good results in a high percentage of patients in stage III disease, alternative modes of therapy may be considered in stage I or stage II disease without jeopardizing the ultimate result from SRA in stage III disease.

Free palmar skin grafts for resurfacing digital defects.

Since 1968, lost skin from the volar aspects of digits has been replaced by full-thickness skin grafts from the thenar area in 40 patients. Durable coverage was obtained in all. No morbidity occurred in the donor site.

Ulnar midcarpal instability-clinical and laboratory analysis.

Patients with ulnar midcarpal instability have a characteristic pattern of clinical signs and symptoms related to the midcarpal joint. The usual presenting complaint is a painful wrist click which can be reproduced by ulnar deviation, axial compression, and pronation of the wrist. Routine x-rays are usually normal, but cinefluoroscopy reveals sudden dissociation between the proximal and distal carpal rows resulting in a dorsiflexion collapse deformity. In six of our patients, conservative therapy sufficed to relieve symptoms. Four other patients required surgical stabilization. We close to stabilize the triquetrohamate joint because it was a relatively easy procedure and eliminated instability in most instances. Laboratory studies aided in understanding the pathomechanics of midcarpal instability, which consisted of dorsal subluxation of the capitate and hamate on the lunate and triquetrum. We believe that midcarpal instability is not a rare condition but may often be confused clinically with more common carpal dissociations.

Infiltrating (intramuscular) lipomas and angiolipomas. A clinicopathologic study of six cases.

Infiltrating (intramuscular) lipomas and angiolipomas are benign mesenchymal tumors that usually appear as a deep, nontender mass within soft tissue, particularly in the extremities. The average tumor size in six cases studied was 11.2 cm (range, 2.0 to 22.0 cm). On gross examination, these tumors are circumscribed but unencapsulated, with infiltration of adjacent skeletal muscle. The correct preoperative diagnosis is seldom made, and the characteristic infiltrating pattern seen microscopically can lead to a mistaken diagnosis of sarcoma. Soft-tissue roentgenograms can be helpful in diagnosis and localization. The recommended mode of therapy is complete local excision with tumor-free soft-tissue margins. None of the six patients described here have experienced recurrence of tumor an average of two years after surgical resection. Prolonged follow-up is recommended, however, since inadequate resection can result in late tumor recurrence.

Carpal tunnel release under local anesthesia: evaluation of the outpatient procedure.

In 100 consecutive cases of carpal tunnel release done under local anesthesia in an outpatient ambulatory care operating room, 93 had satisfactory results at 6 months without any complications. Two patients developed a neuroma of the palmar cutaneous branch of the median nerve, and five showed early signs of reflex sympathetic dystrophy. These complications are discussed, as well as the prevention of other complications of this procedure.

Fibular autografts for distal defects of the radius.

A protocol for osteoarticular grafting was established to avoid fracture, nonunion, and loss of motion when replacing the distal radius. Proximal fibular autografts were used and stabilized proximally by compression plating and, at the wrist, by ligamentous reconstruction. Postoperative splinting and therapy were coordinated with graft healing, which was monitored by bone scans and roentgenograms. Graft incorporation in three patients appeared to be well-established within 1 year, but functional use of the extremity and return to duty were achieved much earlier.