Finger joint injuries in active patients: pointers for acute and late-phase management.

Finger joint injuries such as sprains, avulsions, jams, and dislocations can occur with contact and noncontact sports. Recognition and treatment of these injuries is necessary to avoid prolonged or permanent impairment. Many finger joint injuries can be treated conservatively with splinting and occupational therapy. Injuries such as 'mallet finger,' profundus tendon avulsions, large-fragment fracture-dislocations or other injuries with incongruity after reduction, and open extensor-mechanism injuries may require operative treatment. Operative treatment for complete collateral ligament ruptures at the PIP joint, though controversial, is recommended here.

Epicondylar resection with anconeus muscle transfer for chronic lateral epicondylitis.

A retrospective evaluation of 61 patients surgically treated for persistent lateral epicondylitis, covering the 8-year period between 1982 and 1990, was conducted. The study compared a group of patients treated by limited surgical resection of the lateral extensor aponeurosis with a group of patients treated by wide surgical excision of the aponeurosis and coverage by a vascularized rotational pedicle flap of the anconeus muscle. This is a new procedure that uses the vascular pedicle of the anconeus muscle, rotating it into the defect created by the wide excision. Evaluation at an average of 48 months after surgery indicates that compared with the limited surgical resection group, a higher percentage of patients in the anconeus muscle transfer group were able to perform strenuous activities with complete or near-complete pain relief. A higher percentage also returned to work or to normal activities; 94% of the patients were satisfied with the results of the procedure. This study indicates that this is an effective primary operative treatment for lateral epicondylitis when conservative treatment has failed. It also is effective in patients who continue to have persistent pain and inability to perform normal activities after previous lateral epicondylar release or resection.

Biomechanical analysis of capitate shortening with capitate hamate fusion in the treatment of Kienböck's disease.

The biomechanical effects of surgical treatment options for Kienböck's disease have been compared. However, no study has included a direct analysis of capitate shortening along with capitate-hamate fusion (CSCHF). To investigate the biomechanical effects of CSCHF, a cadaver model of the upper extremity was used to determine radiocarpal articular pressure changes resulting from this procedure using pressure-sensitive film. Ten specimens were tested by placing each in an apparatus that applied load across the radiocarpal joint through the wrist flexor and extensor tendons. Testing was performed in 3 wrist positions (ulnar deviation, radial deviation, and neutral) combined with 3 forearm positions (pronation, supination, and neutral) and neutral flexion/extension. Radioscaphoid, radiolunate, and mean contact pressures in the entire radiocarpal joint were determined for each of the 9 wrist positions, both intact and after surgery. The radioscaphoid mean pressure increased in 6 of 9 positions and was unchanged in 3 positions. The radiolunate mean pressure decreased in 9 of 9 positions. The radiocarpal mean pressure increased in 2 of 9 positions and was unchanged in 7 positions. These data suggests that CSCHF increases radioscaphoid mean pressure, decreases radiolunate mean pressure, and has little effect on radiocarpal mean pressure.

A technique to quantitate motor recovery following nerve grafting.

Sixteen patients were evaluated retrospectively following grafting of an upper extremity peripheral nerve injury. In addition to the standard subjective muscle grading, the force of reinnervated muscle groups was quantitatively measured using force transducers, and reported relative to the contralateral side. Patients recovered a median motor grade of M3, which correlated to a 32% recovery of muscle force of the contralateral side. M3 and M4 motor grades encompassed a large range of actual muscle force: M3 correlated with a recovered force that ranged from 17% to 42%, M4 with a range of 66% to 79%. The percent force of motor recovery decreased significantly with longer delays to nerve grafting, even when controlling for the severity of the injury. Similarly, recovery of muscle force decreased when longer segments of nerve grafts were used. Testing the return of muscle strength after peripheral nerve injuries with a standardized objective system that compares function to the uninjured side enhances the sensitivity of evaluating nerve regeneration and provides a measurement system that can facilitate the comparison of different nerve repair techniques.

Structure functional expression and spatial distribution of a cloned cDNA encoding a rat 5-HT1D-like receptor.

Using polymerase chain reaction (PCR) a complementary DNA (cDNA) encoding a 5-hydroxytryptamine (5-HT) receptor was isolated from rat forebrain. The amplified cDNA specifies an open reading frame of 374 amino acids comprising seven putative transmembrane regions. Expression of the cloned cDNA in human embryonic kidney cells (HEK 293) was used to establish the pharmacological profile of the encoded receptor polypeptide. Membranes containing the cloned receptor showed high affinity binding of [3H]-5-HT. Competition binding experiments with a variety of serotonin receptor ligands displayed a rank order of affinities corresponding to a 5-HT1D subtype: 5-CT > 5-HT = metergoline > CGS 12066 > methysergide > sumatriptan > mianserin = (-)alpha-Me-5-HT = yohimbine > 8-OH-DPAT > or = rauwolscine > spiperone > DOI > propranolol > or = 2-Me-5-HT > or = ICS 205930. Ketanserin and ritanserin displaced [3H]-5-HT-binding in a biphasic manner. In situ hybridization revealed highest expression of the corresponding mRNA in the pyramidal layer of the olfactory tubercle and the nucleus caudatus and accumbens.

Radial nerve palsy caused by open humeral shaft fractures.

Although radial nerve palsy associated with a closed humeral shaft fracture may be managed by observation, it is our experience that an open humeral shaft fracture with radial nerve palsy requires exploration of the nerve. In a series of 14 patients with radial nerve palsy caused by an open humeral shaft fracture, 9 (64%) of the 14 patients had a radial nerve that was either lacerated or interposed between the fracture fragments. There was an equal incidence of radial nerve lacerations or entrapments in types I, II, and III open humeral shaft fractures. Epineural radial nerve repair, done primarily or secondarily, provided a satisfactory return of radial nerve function. Rigid fixation of the associated fracture is the recommended treatment.

A comparison of scaphoid-trapezium-trapezoid fusion and four-bone tendon weave for scapholunate dissociation.

The contact characteristics of the radiocarpal joint (area, pressure, and ratios of scapholunate area, pressure and force transmitted) were determined with the use of pressure-sensitive film in seven normal wrists after ligament sectioning to create scapholunate instability, with reconstruction involving a scaphoid-trapezium-trapezoid fusion, and with reconstruction involving a four-bone tendon weave procedure. The results demonstrated that the scaphoid-trapezium-trapezoid fusion significantly altered the contact characteristics of the wrist, transferring load, pressure, and area to the radioscaphoid joint, thereby unloading the lunate. In contrast, the tendon weave reconstruction produced characteristics similar to those of the normal joint.

Proximal row fusion as a solution for radiocarpal arthritis.

A retrospective study evaluated the function of thirty-six patients treated by radius-scaphoid-lunate arthrodesis for painful posttraumatic radiocarpal arthritis from 1982 through 1987, and determined whether the procedure created arthritis or other functional problems in the remaining joints. Thirty-one men and five women with a mean age of 41 years were studied. The standard surgical technique employed iliac crest bone graft and internal fixation. Seven patients required revision of the proximal fusion to complete wrist fusion because of pain; arthritic changes in the midcarpal joint had been noted in these patients at the time of the limited fusion. The remaining twenty-nine patients required no further surgical treatment. Grip strength averaged 70% of the uninvolved side. The average arc of wrist flexion and extension was forty-eight degrees. Eighteen patients returned to their original employment, in many cases to heavy labor. Five did not return to work because of wrist problems. We conclude that the probability of a good functional result is high for this procedure if there is no midcarpal arthritis.

Four-bone ligament reconstruction for treatment of chronic complete scapholunate separation.

This study reviews the results of a four-bone ligamentous weave reconstruction for treatment of chronic complete scapholunate separation. This reconstruction between the radius, lunate, capitate, and scaphoid employs a dorsal and palmar approach weaving a long strip of the extensor carpi radialis brevis through the four bones reducing and stabilizing the scaphoid and lunate with a wire loop. Thirty-six consecutive cases of operated chronic complete scapholunate separation were evaluated in a 2- to 10-year follow-up. Average length of follow-up was 4.8 years. Average age was 34 years. Average postoperative range of motion was 52 degrees extension and 37 degrees flexion. Grip strength averaged 73% of the noninvolved side. All preoperative scapholunate gaps seen on radiographs were greater than 4 mm, at surgery greater than 1.0 cm, and the postoperative gaps radiographically averaged 3.3 mm. Eighty-six percent of patients returned to preinjury activities including heavy labor. The most significant finding was no x-ray evidence of advancing arthritic changes.

Plates versus external fixation in severe open tibial shaft fractures. A randomized trial.

A prospective study of 59 patients with Grade II or III open tibial shaft fractures compared internal and external fixation. Bony stabilization was with plating by AO principles or with external fixation with the one-half pin technique, prospectively randomized. In 12 cases, minimal internal fixation of the tibia and external fixation were combined. Definitive wound closure was delayed in all cases. Three free-flap transfers and two gastrocnemius myoplasties were done; vascular injury necessitated three early limb amputations. Fifty-six patients were followed for at least one year. Five plate fixations (19%) were complicated by severe osteomyelitis, and three plate fixations failed. Severe osteomyelitis occurred in one case (3%) treated with external fixation. Three pin-tract infections occurred. In two patients, a 10 degrees anteroposterior angulation occurred after external fixation removal. One patient healed with a 25 degrees external rotation deformity. At final follow-up evaluation, all tibial shaft fractures had healed. Knee and ankle ranges of motion were affected by ipsilateral femoral shaft fracture, knee injury, or ankle and foot trauma but not by the type of fixation. Both methods yielded excellent results, but the rate and extent of complications were lower with external fixation. Therefore, external fixation using the one-half pin technique should be regarded as a primary method of stabilization for Grades II and III open tibial shaft fractures.

Structure and functional expression of cloned rat serotonin 5HT-2 receptor.

A complementary DNA (cDNA) encoding a serotonin receptor with 51% sequence identity to the 5HT-1C subtype was isolated from a rat brain cDNA library by homology screening. Transient expression of the cloned cDNA in mammalian cells was used to establish the pharmacological profile of the encoded receptor polypeptide. Membranes from transfected cells showed high-affinity binding of the serotonin antagonists spiperone, ketanserin and mianserin, low affinity for haloperidol (a dopamine D2 receptor antagonist), 8-OH-DPAT as well as MDL-72222 and no detectable binding of [3H]serotonin. This profile is consonant with the 5HT-2 subtype of serotonin receptors. In agreement with this assignment, serotonin increased the intracellular Ca2+ concentration and activated phosphoinositide hydrolysis in transfected mammalian cells. The agonist also elicited a current flow, blocked by spiperone, in Xenopus oocytes injected with in vitro synthesized RNA containing the cloned nucleotide sequences.

cDNA cloning of human liver monoamine oxidase A and B: molecular basis of differences in enzymatic properties.

The monoamine oxidases play a vital role in the metabolism of biogenic amines in the central nervous system and in peripheral tissues. Using oligonucleotide probes derived from three sequenced peptide fragments, we have isolated cDNA clones that encode the A and B forms of monoamine oxidase and have determined the nucleotide sequences of these cDNAs. Comparison of the deduced amino acid sequences shows that the A and B forms have subunit molecular weights of 59,700 and 58,800, respectively, and have 70% sequence identity. Both sequences contain the pentapeptide Ser-Gly-Gly-Cys-Tyr, in which the obligatory cofactor FAD is covalently bound to cysteine. Based on differences in primary amino acid sequences and RNA gel blot analysis of mRNAs, the A and B forms of monoamine oxidase appear to be derived from separate genes.

Concurrent oral surgery and orthopaedic treatment in the multiply injured patient: is there an increased incidence of orthopaedic sepsis?

Fifty-five patients requiring oral surgery and orthopaedic care were studied prospectively and compared to a control group. Six patients received no antibiotics and one developed an orthopaedic operative site infection due to a mouth organism. Seventeen patients had concurrent surgery and perioperative antibiotic usage and no infections occurred. Twenty-six patients required multiple operations and courses of antibiotic treatment and five developed infections. Enterobacter infections were common and emerge because they are resistant to first-generation cephalosporins. Treatment by a perioperative first-generation cephalosporin is recommended, followed by throat cultures and treatment by antibiotics specific for cultured organisms for patients requiring subsequent operations.

Treatment of unstable femoral shaft fractures with closed interlocking intramedullary nailing.

From 1979 to 1982, 64 femoral shaft fractures in 62 patients were treated by closed interlocking nailing at Harborview Medical Center, Seattle, WA, U.S.A., and Parkland Memorial Hospital, Dallas, TX, U.S.A. Twenty-nine patients sustained multiple system injuries and 29 of the involved extremities (45%) had at least one additional injury. There were 17 (26%) open fractures. Static mode nailing was used to treat 52 fractures; dynamic mode nailing was performed for 12 fractures. Patient follow-up averaged 17 months (range 7-41 months). The average time to union was 13.5 weeks. Normal femoral length within 1 cm was achieved in 97% of cases. Knee range of motion averaged 127 degrees. Complications (9%) included two delayed unions, one nonunion, two cases of shortening or lengthening of more than 1 cm, and one case of malunion with angulation or more than 10 degrees. The delayed unions and nonunions healed after one additional procedure. This study shows that closed interlocking nailing is a safe, effective technique that provides stable fixation in most unstable femoral shaft fractures. This technique represents a major advance in the treatment of difficult femoral shaft fractures that would be poorly suited for standard closed nailing.

Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study.

We performed ninety-six internal-fixation procedures for fracture or non-union of the humeral shaft in eighty-four patients, with a mean follow-up of 32.6 months (range, three months to fourteen years). The primary indications for operative intervention included humeral shaft fracture in a patient with multiple trauma, non-union, inadequate reduction of a humeral shaft fracture by closed methods, pathological humeral-shaft fracture, and progressive radial-nerve palsy. Methods of internal fixation included compression plates and screws and intramedullary Küntscher nails or Rush rods. The use of an AO/ASIF compression plate or interfragmentary lag screws with an AO/ASIF neutralization plate in twenty-seven multiply-injured patients resulted in a union rate of 100 per cent and generally good motion of the shoulder and elbow. Five multiply-injured patients also obtained good results through fixation by a modified Hackethal technique using two Rush rods. The use of intramedullary Küntscher nails resulted in a rate of union of 91 per cent in eleven multiply injured patients. Ten patients with non-union of a humeral shaft fracture had an 80 per cent rate of union with the use of an AO/ASIF compression plate. The use of a Küntscher nail in eleven patients with non-union resulted in a rate of union of only 73 per cent and frequently caused subacromial impingement. Fractures of the humeral shaft that had had an inadequate reduction by closed means or were associated with progressive radial-nerve palsy were best managed by a compression plate or the modified Hackethal technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Open tibial fractures with associated vascular injuries: prognosis for limb salvage.

Open tibial fractures complicated by limb-threatening vascular injuries present an infrequent but difficult management problem. Twenty-three cases were reviewed with an ultimate amputation rate of 61% (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and revascularization delays of greater than 6 hours were associated with a bad outcome. Guidelines for primary amputation (crushing injuries, delay in revascularization, segmental tibial fractures) are proposed and implications of limb salvage are reviewed.

CT of acetabular fractures: postoperative appearances.

Thirty-one postoperative pelvic computed tomographic (CT) scans in 29 patients studied between 1 day and 7 years after open reduction and internal fixation of acetabular fractures were reviewed. CT was most useful in the immediate postoperative period for detecting residual intraarticular fragments, localizing metallic fixation devices, and assessing the adequacy of reduction. CT scans obtained in the late postoperative period were useful primarily for determining the position and extent of ectopic bone before surgical removal.

Fat release after femur nailing in the dog.

Internal fixation of fractures in the first few hours following injury has important advantages. It can diminish continued blood loss, improve patient mobility, and may help avoid pulmonary and cardiovascular complications of multiple trauma. Fear of increased risk of fat embolism has limited its use. We studied the release of fat during intramedullary reaming and nailing of the femur in dogs. Comparing fat release from an intact and a fractured femur in each dog, significantly more triglyceride was released from the intact bone than from the fractured femur. Thus, reaming a fractured bone produces minimal embolization. The presence of a fracture may decompress the pressure in the medullary canal, minimizing the release of fat into the circulation during acute internal fixation. This could help to explain the low incidence of clinical fat embolism syndrome associated with immediate intramedullary nailing of the femur.

Transcutaneous PO2: a potential monitor the status of replanted limb parts.

In animal and human investigations, transcutaneous PO2 proved to be a sensitive and rapid indicator of the patency of the artery and veins supplying a limb part. Furthermore, transcutaneous PO2 indicated the presence or absence of collateral circulation. Commercially available transcutaneous PO2 probes were easily applied to human fingers and dramatically reflected the compromise of finger circulation by the inflation of a blood-pressure cuff around the arm. Probe temperatures from 42 to 44 degrees C appeared to provide satisfactory sensitivity and safety. On the basis of these studies, we conclude that transcutaneous PO2 monitoring holds sufficient potential for the evaluation of replanted limb parts to deserve a clinical trial.