The role of arthrodesis of the wrist in spastic disorders.

We investigated the functional and radiographic outcome of wrist arthrodesis in 11 adults with spastic wrist deformities, carried out by one surgeon between 2003 and 2012. The underlying cause of spasticity was a cerebrovascular insult in five, traumatic brain injury in four, and cerebral palsy in two patients. A dorsal plate and local bone graft was used in all patients. The mean radiographic flexion deformity significantly improved from 67° pre-operatively to 4° of dorsal angulation post-operatively. Thumb-in-palm deformity was more pronounced in three patients after the operation. The functional House score improved in all patients an average of two levels (range 1-3).

Risk factors for return with a second trigger digit.

The purpose of this study was to determine predictors of return to the same practice with a second idiopathic trigger digit. A total of 2234 patients with Quinnell grade 2 or greater (objective triggering) of one or more digits were retrospectively analysed. A total of 490 of 2234 (22%) patients returned to the same practice with a second trigger digit, with an average follow-up time of 2.1 years (range, 7 days to 10 years). Predictors of return with a second trigger digit included carpal tunnel syndrome, Type 1 diabetes mellitus and duration of follow-up in years. Patients diagnosed with idiopathic trigger digit can be advised that about one in five will return to the same practice with another trigger digit, with approximately double the risk in patients that have carpal tunnel syndrome or Type 1 diabetes.

Evaluation of the scratch collapse test for the diagnosis of carpal tunnel syndrome.

This prospective study measured and compared the diagnostic performance characteristics of various clinical signs and physical examination manoeuvres for carpal tunnel syndrome (CTS), including the scratch collapse test. Eighty-eight adult patients that were prescribed electrophysiological testing to diagnose CTS were enrolled in the study. Attending surgeons documented symptoms and results of standard clinical manoeuvres. The scratch collapse test had a sensitivity of 31%, which was significantly lower than the sensitivity of Phalen's test (67%), Durkan's test (77%), Tinel's test (43%), CTS-6 lax (88%), and CTS-6 stringent (54%). The scratch test had a specificity of 61%, which was significantly lower than the specificity of thenar atrophy (96%) and significantly higher than the specificity of Durkan's test (18%) and CTS-6 lax (13%). The sensitivity of the scratch collapse test was not superior to other clinical signs and physical examination manoeuvers for CTS, and the specificity of the scratch collapse test was superior to that of Durkan's test and CTS-6 lax. Further studies should seek to limit the influence of a patient's clinical presentation on scratch test performance and assess the scratch test's inter-rater reliability.

Correspondence between clinical presentation and electrophysiological testing for potential carpal tunnel syndrome.

The diagnosis of carpal tunnel syndrome (CTS) is often applied in the absence of objectively verifiable pathophysiology (i.e. electrophysiologically normal carpal tunnel syndrome). The primary purpose of this study was to determine whether depressive symptoms, heightened illness concern, and pain catastrophizing are associated with an absence of electrophysiological abnormalities. The secondary purpose was to examine the correspondence between the Levine scale, the CTS-6, and electrophysiological abnormalities. Ninety-eight participants completed validated questionnaires assessing psychosocial factors at the initial visit, and surgeons recorded clinical data and their confidence that the diagnosis was carpal tunnel syndrome. Symptoms and signs that are characteristic of carpal tunnel syndrome (e.g. the CTS-6 and Levine scale) significantly, but incompletely coincided with electrophysiological testing. Psychological factors did not help distinguish patients with normal and abnormal objective testing and it remains unclear if symptoms that do not coincide with abnormal tests represent very mild, immeasurable median nerve dysfunction or a different illness altogether. Future studies should address whether outcomes are superior and resource utilization is optimized when surgery is offered based on symptoms and signs (e.g. the CTS-6) or when surgery is offered on the basis of measurable pathophysiology.

Plate fixation in closed ipsilateral multiple metacarpal fractures.

Closed multiple metacarpal fractures are uncommon. They are usually associated with significant soft tissue swelling. Early stable fixation and functional rehabilitation optimises outcome. We present a review of 19 patients with 43 metacarpal fractures treated by early open reduction and internal fixation with 2 mm plates. Eighteen patients recovered a full range of motion, while one patient was lost to follow-up. Implant removal on account of extensor irritation was required in only two metacarpals in two patients. Plating of multiple closed metacarpal fractures is a safe, reliable and consistently reproducible treatment method.

Combined fractures of the distal radius and scaphoid.

Combined fractures of the distal radius and scaphoid are uncommon, are usually the result of a high-energy trauma and there is no consensus regarding their optimal management. We present a retrospective study of ten patients, out of whom nine underwent internal fixation of their fractures. Open reduction and internal fixation were performed in six of the eight intraarticular fractures of the distal radius. After a mean follow-up of 40 months, eight patients reported no pain and the mean range of wrist motion was 55 degrees flexion and 71 degrees extension. Our current management protocol is outlined. Emphasis on treatment of this combined fracture should be placed on the management of the distal radius fracture. Internal fixation of both fractures, followed by early rehabilitation, optimises outcomes. Cast treatment is indicated only in patients with completely undisplaced fractures of both the radius and the scaphoid.

Recurrent intravascular papillary endothelial hyperplasia of the right middle finger treated with radiation therapy.

We describe a case of recurrent intravascular papillary endothelial hyperplasia involving the middle finger which was successfully-treated with photon and proton radiotherapy following two previous surgical excisions.

Closed traumatic rupture of the extensor digitorum communis and extensor indicis proprius at the musculo-tendinous junction.

This report describes a closed rupture of the entire extensor digitorum communis and extensor indicis proprius.

Management of tophaceous gout of the distal interphalangeal joint.

Surgical management of acute tophaceous gout of the distal interphalangeal joint is often associated with delayed wound healing. Aspiration through neighbouring uninvolved skin is a safe method of treating these tophi. For persistently symptomatic, unstable DIP joints, arthrodesis should be considered.

Flexon-type Salter-Harris I injury of the proximal tibial epiphysis.

The authors report a case of a flexion-type epiphyseal separation of the proximal tibia. The injury described herein is a displaced Salter-Harris type I injury. Literature pertaining to this rare injury is reviewed, and management options are discussed.

Reconstruction of Achilles tendon defect with a free quadriceps bone-tendon graft without anastamosis.

We report a method of Achilles tendon reconstruction using a free quadriceps bone-tendon graft. The patient had a prior repair of a re-ruptured Achilles tendon, following which he developed massive necrosis of his skin and Achilles tendon leaving a 10 cm defect. First stage reconstruction consisted of soft tissue coverage of the skin defect with a sural fasciocutaneous flap. Reconstruction of the Achilles tendon followed, with the patellar bone block fixed to the calcaneus and the quadriceps tendon sutured proximally.

Radiocarpal fracture-dislocation.

Radiocarpal fracture-dislocation is an uncommon but complex injury that is often the result of high energy trauma. The combination of ligamentous and osseous injuries demands meticulous attention to restoration of anatomy, especially of the radial styloid. Open reduction and internal fixation is often necessary to restore the relationship of the end of the radius to the carpus and distal ulna. We present a retrospective review of 12 patients treated over a 10-year period and review the literature.

Use of non-cannulated screws in fixation of subcapital fractured necks of femur.

We have reviewed twenty cases of subcapital femoral neck fractures fixed internally with non-cannulated screws. These were used in the absence of a cannulated screw system, a problem faced in many centres. The authors describe a method of placing parallel screws without special jigs using AO guidewires and taps. A small incision is used and recommended. The approach is especially recommended in old, frail patients.

Scapho-lunate diastasis: a component of fractures of the distal radius.

Ten cases of fractures of the distal radius associated with scapho-lunate diastasis are reported. The mechanism of injury has been described and an attempt made to analyse the implications in treating such an injury.