Neglected isolated scaphoid dislocation.

The authors present a case of isolated scaphoid dislocation in a 40-year-old male that was undiagnosed for 2 months. The patient was treated by open reduction, Kirschner wire fixation, interosseous ligament repair using a suture anchor and Blatt's dorsal capsulodesis. At 6 years followup, his radiographs of wrist showed a normal carpal alignment with a scapholunate gap of 3 mm and no evidence of avascular necrosis (AVN) of the scaphoid.

A randomized comparison of volar plate and external fixation for intra-articular distal radius fractures.

PURPOSE: To compare surgical outcomes of volar locking plates (VP) and external fixation (EF) (with or without intra-focal fixation) for AO-type C2 and C3 fractures of the distal radius. METHODS: From an initial group of 92 patients with AO-type C2 and C3 distal radius fractures who were enrolled in a prospective, randomized study comparing volar plate fixation with external fixation (with or without intra-focal fixation), 74 patients were studied. The researchers evaluated functional assessments (wrist range of motion, grip strength, and Michigan Hand Questionnaire) at each patient visit and measured radiographic assessment (radial inclination, volar tilt, ulnar variance, and articular congruity) at 12 months. RESULTS: The grip strength of the VP group was significantly greater than that of the EF group at 3 and 6 months. The range of motion was significantly greater in the VP group than in the EF group at 3 months. There were no significant differences in the range of motion and grip strength between the 2 groups at 12 months. The Michigan Hand Questionnaire score was higher in the VP group than in the EF group at 3 months but was same at 12 months. There was no significant difference between groups with respect to volar tilt or radial inclination. The VP group showed superior radiologic outcomes in terms of the ulnar variance. One patient in the VP group and 3 in the EF group had an intra-articular stepoff deformity greater than 2 mm. This difference did not reach statistical significance. CONCLUSIONS: These results for functional recovery after distal radius surgery offer insight into treatment decisions and interpretations of treatment outcomes for patients with comminuted intra-articular distal radius fractures.

Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture.

PURPOSE: Wrist fracture is considered a typical initiating trauma for complex regional pain syndrome type I (CRPS I). However, few studies have comprehensively evaluated factors associated with the occurrence of CRPS I after the surgical treatment of a distal radius fracture (DRF). This study evaluates the factors influencing the occurrence of CRPS I after the surgical treatment of a DRF. METHODS: A total of 477 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. Patients were followed for 6 months after surgery, and CRPS I was diagnosed using the Budapest diagnostic criteria for research. The factors assessed for the development of CPRS I were age, gender, the body mass index, the type of fracture, the energy of trauma, the number of trial reductions, the type of surgery, and the duration of immobilization. A multivariate logistic regression analysis was conducted to identify independent predictors of the occurrence of CRPS I. RESULTS: Among the 477 patients, 42 (8.8 %) satisfied the Budapest criteria for CRPS I within 6 months of surgery. Female patients developed CRPS I more frequently, and the patients who developed CRPS I were older and more likely to sustain a high energy injury or have a comminuted fracture. According to the multivariate analysis, female patients and those with a high energy trauma or severe fracture type were significantly more likely to develop CRPS I (p = 0.02, 0.01, and 0.01, respectively). CONCLUSIONS: High energy injuries, severe fractures, and the female gender contribute to the development of CRPS I after the surgical treatment of DRF. The results have important implications for physicians who wish to identify patients at high risk for CRPS I after operative fixation for DRF and instigate treatment accordingly.

Reliability and validity of carpal alignment measurements in evaluating deformities of scaphoid fractures.

PURPOSE: Several radiographic carpal alignment indices are used to evaluate the deformities of scaphoid fractures. The purpose of this study was to determine the reliabilities and validities of radiographic carpal alignment indices commonly used to evaluate deformities of scaphoid fractures. METHODS: Thirty-six patients with a scaphoid fracture were evaluated. Five carpal alignment indices were assessed on lateral plain radiographs, namely, scapholunate angle, radioscaphoid angle, radiolunate angle, radiocapitate angle, and capitolunate angle. Three examiners measured these radiographic indices at two sessions, and intraobserver and interobserver reliabilities were determined and expressed as intraclass correlation coefficients. Discriminant validities of radiographic carpal alignment indicies between injured and uninjured wrists were evaluated. For convergent validity testing, the correlation between the radiographic carpal alignment indices and intrascaphoid angles (ISAs) or height-to-length (HL) ratios on CT longitudinal scans was assessed. Further, carpal alignment indices after surgical reconstruction were compared to the Mayo wrist score. RESULTS: Scapholunate and radiolunate angles had the highest reliabilities, and radiocapitate angle had the lowest. Radiolunate angle had the highest discriminant validity followed by scapholunate, and capitolunate angles. In convergent validity testing, scapholunate angles and radiolunate angles correlated with ISA angles, and radiolunate and capitolunate angles correlated with HL ratios. Only the radiolunate angles correlated with the Mayo wrist scores. CONCLUSIONS: Among radiographic carpal alignment measures, radiolunate angle is the most reliable and valid carpal alignment index for evaluating deformities of scaphoid fractures. Scapholunate and capitolunate angles could be used as an alternative, but have less validity.

Sagittal and coronal plane location of the popliteal artery in the open-wedge high tibial osteotomy.

PURPOSE: The objectives of this study were (1) to evaluate the sagittal and coronal plane location of the popliteal artery during the advancement of open-wedge high tibial osteotomy and (2) to confirm the effect of osteoarthritis if it changes the relationship between the popliteal artery and posterior cortex. METHODS: Two hundred consecutive patients were enrolled, and we divided patients into two subgroups according to age and cartilage status in the radiologic report of magnetic resonance imaging (group I: 100 non-arthritic knees; group II: 100 arthritic knees). For prediction of the location of the popliteal artery during the operation, sagittal and coronal plane location along the osteotomy plane was evaluated. RESULTS: The distance between the posterior cortex of the osteotomy and popliteal artery was 13-14 mm on the sagittal plane, and the popliteal artery was located at an approximately 35 ± 5.5 mm portion from the starting point of the osteotomy on the coronal plane. The distance at the starting point of osteotomy was larger than at the end portion and prominent area. In comparison between groups I and II, group II showed a larger distance on the sagittal planes [osteotomy-vascular: 13.6 vs 14.4 (p = 0.01), fibula-vascular: 4.88 vs 6.5 (p < 0.01), and prominence-vascular: 4.3 vs 5.3 (p < 0.01)] compared to the group I. CONCLUSIONS: Special caution and some protection should be given until the approximately 35 mm portion from the starting point of the posteromedial cortex with consideration for the approximity on the sagittal plane. In comparison between the non-arthritic and arthritic knee, differences were observed on the sagittal plane. However, the value was minimal, and the clinical relevance was questionable. LEVEL OF EVIDENCE: Case series, Level IV.

Ganglion cysts of the posterior cruciate ligament.

Ganglion cysts of the posterior cruciate ligament (PCL) are uncommon lesions found incidentally on MRI and arthroscopy. Twenty patients (11 males and nine females) with the mean age of 35 years presenting with a variety of knee signs and symptoms were found to have PCL cysts on MRI. Out of these, thirteen patients (65%) had isolated symptomatic PCL cysts and seven patients had associated chondral and meniscal lesions. Eight out of the 20 patients (40%) gave a history of antecedent trauma. On arthroscopy, the majority of the cysts were situated at the midsubstance of the ligament with inter-cruciate distension and no involvement of the substance of the ligament. The content of the cysts varied with the majority having yellowish viscous fluid and three containing serous and bloody fluid. All cysts were successfully treated arthroscopically through standard anterior, posteromedial and posterolateral portals with no signs of recurrence on MRI at a mean followup of 24 months. PCL cysts may clinically mimic meniscal or chondral lesions and preoperatively, MRI is essential for the diagnosis of ganglion cysts arising from the PCL. Ganglion cysts of the PCL can be successfully treated arthroscopically using standard portals.

Proximal humerus Salter type III physeal injury with posterior dislocation.

Salter type 3 fractures of the proximal humerus are rare injuries. We report the first case of a Salter type 3 physeal fracture with posterior dislocation of the proximal humerus in a 16-year-old boy. The fracture pattern could not be evaluated by simple radiography, but was possible with the aid of MRI. The dislocated humeral head was locked behind the glenoid labrum. Open reduction was mandatory. Sixteen months after the operation, avascular necrosis of the humeral head was detected by simple radiography and MRI. Even though the patient had a full range of motion of the shoulder and no pain, a long-term follow-up is believed necessary.

Stress fractures of the femoral diaphysis in children: a report of 5 cases and review of literature.

The authors report five new cases of the stress fracture of the femoral diaphysis in children. These injuries usually occurred without a history of recent increase of activity. Recently regained normal activity after long-term immobilization and a fibrous cortical defect were predisposing factors. The periosteal reactions were usually identified in the initial radiograph and were not confined to the medial cortex of the distal femur; they might occur in any part of the femoral diaphysis, and also concomitantly on the multiple cortex. The atypical radiographic presentations frequently required MRI for differential diagnosis. Even though the MRI may be confusing to the inexperienced observer, it can lead to the diagnosis of a stress fracture with confidence, negating the need for biopsy. Clinicians should be aware of this diagnostic entity in the differential diagnosis of femoral diaphyseal lesions in children because the occurrence might be more common than reported. Serial simple radiographic examinations taken at intervals to look for the evidence of progressive fracture healing and the restriction of activity or immobilization may be an adequate approach for management.

Free vascularized osteocutaneous fibular graft to the tibia in 51 consecutive cases.

The authors reviewed retrospectively the clinical results of 51 consecutive cases of vascularized osteocutaneous fibular graft to the tibia for the reconstruction of extensive tibial bone and soft-tissue defects. The mean duration of follow-up was 31 months (range: 13 to 76 months). In the 51 procedures of free vascularized osteocutaneous fibula graft from the contralateral side, bony union was achieved in 48 cases at an average of 3.74 months after the operation, except for two cases of non-union and two cases of delayed union. Forty-eight cutaneous flaps survived, and three cutaneous flaps failed due to deep infection and venous thrombosis. All united fibulae hypertrophied during the follow-up periods. Stress fracture of the grafted fibula was the most common complication (16 cases), and it was treated with above-the-knee cast immobilization or internal fixation with a conventional cancellous bone graft. The free vascularized osteocutaneous fibular graft is recommended as a useful treatment modality for the reconstruction of extensive tibial defects combined with soft tissue injury.

The neglected rupture of deep transverse metacarpal ligament.

The deep transverse metacarpal ligament (DTML) extends in radio-ulnar direction between the palmar plates of the metacarpophalangeal (MCP) joints of the second through fifth finger rays. On the radial aspect of the index and the ulnar aspect of the small fingers, the ligament merges with the collateral ligament of the MCP joints. The ligament has palmar grooves for the flexor tendons at the MCP joints and act as a support for the metacarpal arch. Closed DTML injury is an unusual case, but the physical findings of DTML injury are a decrease in grip strength, deviation of the finger in flexion and pain on the affected site of the hand. We have experienced a case of neglected DTML injury of left third interdigital space in a 23-year-old man.