Diagnosis and Treatment of Posteromedial Elbow Impingement in the Throwing Athlete.

PURPOSE OF REVIEW: Posteromedial elbow impingement is a common pathological entity in the throwing athlete. The posteromedial articulation of the elbow is a significant stabilizer to medial elbow forces and valgus stress noted during repetitive throwing. This current review investigates recent literature regarding the relevant anatomy, diagnosis, and treatment of posteromedial impingement in the thrower. RECENT FINDINGS: Improvements in advanced imaging have provided accurate and detailed diagnostic capability for the assessment of the throwers' elbow. After failure of conservative measures, arthroscopic treatment of posteromedial elbow impingement with posteromedial osteophyte removal has demonstrated excellent outcomes with a reliable return to play in the competitive thrower. In addition to a thorough history and physical examination, MRI, MR arthrogram, CT, and dynamic ultrasound imaging modalities are useful in the assessment of a presumed diagnosis of posteromedial impingement. Arthroscopic decompression with posteromedial osteophyte removal provides effective clinical results and return to play. The surgeon should be careful to avoid creating medial ulnar collateral instability by means of over-resection of the posteromedial olecranon.

A novel technique for the treatment of recurrent cubital tunnel syndrome: ulnar nerve wrapping with a tissue engineered bioscaffold.

The purpose of this study was to assess subjective and objective outcomes in treating recurrent cubital tunnel at secondary neurolysis by nerve wrapping with a tissue engineered three-dimensional biomatrix. Five patients with a mean age of 44.1 years and an average follow-up of 13.3 months were included in the study. All patients had improvement in visual analogue scales. Four patients that had preoperative intrinsic atrophy with clawing had no clawing or intrinsic atrophy at final follow-up. Postoperatively, four of the five patients had two-point discrimination of 5 mm. Grip strength on average increased 90%. Three patients had an excellent outcome, one patient had a good outcome, and one patient had a fair outcome. All five patients said they would have surgery again.

Ultrasonography for the evaluation of forearm interosseous membrane disruption in a cadaver model.

Recognition of interosseous membrane disruption associated with radial head injury and Essex-Lopresti injury is important, especially if radial head excision is contemplated. Because a widely accepted method to diagnose interosseous membrane disruption does not exist, we evaluated the accuracy of ultrasonography to diagnose this injury in a cadaver model. Nine pairs of cadaver forearms were randomized into 2 groups. The central third of the interosseous membrane of forearms of group 1 was cut, whereas it was visualized but not cut in group 2. A dynamic ultrasound examination was performed to determine interosseous membrane integrity, and static images were made. The static images were evaluated by 2 other radiologists and interpretations were recorded. One radiologist incorrectly interpreted 1 pair of forearms; the other 2 radiologists were 100% accurate. The accuracy of ultrasonography in detecting interosseous injuries was 96% with our methods.

The role and implementation of metacarpophalangeal joint fusion and capsulodesis: indications and treatment alternatives.

Successful surgical reconstruction of the basilar thumb joint requires a thorough knowledge of the longitudinal intercalated collapse that may occur with this condition. Evaluation of the hyperextended thumb MCP joint and appropriate treatment are instrumental to successful basal joint reconstruction. Stabilization of the MCP joint helps maximize return of a pain-free, efficient pinch mechanism. A useful guide to specific reconstructive methods for the MCP joint is presented in Table 1.

Heterotopic ossification after lateral epicondylectomy.

Lateral epicondylitis is a common affliction that can be treated nonsurgically. However, surgical treatment is rarely indicated, and results are usually effective in more than 90% of patients. Although complications have been described, ours is the first report of heterotopic ossification after an uncomplicated lateral epicondylectomy.

Sesamoiditis of the index finger presenting as acute suppurative flexor tenosynovitis.

Sesamoiditis involving the hand is uncommon, usually reported in the thumb, and has not been reported in the index finger. As rare as this clinical entity remains, its presentation simulating an acute suppurative flexor tenosynovitis is even more rare. We report a patient who presented with Kanavel's 4 cardinal signs of acute suppurative tenosynovitis who was subsequently found to have an acute sesamoiditis of the index finger. This finding was supplemented by a cadaveric and radiographic study to better delineate the anatomy of the index sesamoid and further explain the clinical presentation.

Myositis ossificans of the hand.

We present a case of myositis ossificans of the hand and review the clinical, radiological, and histological presentation, as well as the appropriate therapeutic management.

Tilted lateral radiographs in the evaluation of intra-articular distal radius fractures.

The anatomy of the distal radius confounds the assessment of fracture displacement of the lunate facet. Since reduction of the articular surface is paramount to obtaining good clinical results, this study was designed to evaluate whether a radiograph taken 22 degrees from true lateral (forearm held at a 22 degrees angle from the horizontal film cassette) would enhance the accuracy of measuring displacement. Fifteen lunate facet fractures of varying depression were produced in 7 fresh cadaveric wrists. Posteroanterior (PA), standard lateral, and 22 degrees tilted lateral radiographs were obtained of each fracture pattern. Four observers reviewed the films and measured the depression of the fragments from their anatomic position. Measurement error from actual depression averaged 1.1 mm when the evaluators evaluated the 22 degrees lateral and PA films, 1.5 mm for the standard lateral and PA views, and 0.8 mm for the standard lateral, 22 degrees lateral, and PA radiographs (combined group). The decrease in measurement error obtained from all 3 groups was statistically significant. The results of this study suggest that the 22 degrees tilted lateral, either in combination with the standard lateral radiograph or just with the PA view, may help the hand surgeon better understand the intra-articular depression of lunate facet fractures of the distal radius.

Abducted, hyperextended small finger deformity of nonneurologic etiology.

The abduction and hyperextension deformity of the small finger is usually associated with ulnar nerve palsy. Six patients who sustained an abduction force to their small finger presented with the finger in an abducted and hyperextended position. All patients were neurologically intact and were unable to adduct or flex the finger at the metacarpophalangeal joint. Surgical findings in these patients included rupture of the radial sagittal band, collateral ligament, and junctura tendinum. Sequential division of these structures in cadaveric hands confirmed that all these tissues had to be deficient for this deformity to occur. The traumatic abducted, hyperextended small finger deformity may respond to conservative treatment, but surgery is sometimes necessary.

Acute compartmental syndrome from hematogenous osteomyelitis of the ulna.

Compartmental syndrome of the forearm in children is usually caused by fractures, soft-tissue damage, burns, or arterial injury. This report presents the case of a child who had compartmental syndrome of the forearm resulting from acute hematogenous osteomyelitis of the ulna.

A method to locate the radial digital nerve of the index finger.

The radial digital nerve of the index finger is susceptible to injury during penetrating trauma or elective release of the A1 pulley. The intersection of a line drawn down the midline of the index finger and the proximal palmar crease identifies the location of the radial digital nerve. This method of identifying the topography of the nerve should assist the surgeon in determining the likelihood of injury after penetrating trauma, and preventing injury during elective procedures.

Two open forearm fractures after airbag deployment during low speed accidents.

Automotive airbags effectively mitigate the impact of vehicular collision by absorbing and distributing a force that otherwise would be sustained by the occupants. To be effective, inflation must be instantaneous and sufficient to provide restraint to a moving body. Deployment of automotive airbags is a violent event that may cause injury to the occupants of the vehicle. This report describes two patients with severe, open radius and ulna fractures that were caused by airbag inflation during low velocity motor vehicle accidents. The degree of soft tissue injury and bone comminution in these patients was not fully appreciated until surgery. Orthopaedic surgeons should be aware of the explosive nature of airbag deployment and realize that the injury may be far greater than expected from a low energy motor vehicle accident.

Radial longitudinal deficiency. A review and update.

Treatment of patients with radial longitudinal deficiency remains challenging for the hand surgeon. A thorough knowledge of the anomalous anatomy and the varied presentation is vital to effect a sound treatment plan. This article includes a review of the pertinent historical background, a discussion of current recommendations, and a detailed critical review of recent contributions to the field.

Static external fixation in the hand and carpus.

Static external fixation in the hand and carpus remains a valuable part of the hand surgeon's armamentarium for the treatment of complex injuries. This article describes a brief history, indications, case examples, and complications using these constructs. Pertinent pitfalls are emphasized to avoid suboptimal outcomes.

The hypothenar fat pad flap for management of recalcitrant carpal tunnel syndrome.

The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence between the median nerve and overlying transverse carpal ligament and surgical scar. This retrospective study reviews 62 hands in 58 patients (46 non-workers' compensation and 16 workers' compensation) with recurrent symptoms after failed open carpal tunnel release who underwent revision carpal tunnel decompression and in whom a hypothenar fat pad flap was used. The follow-up period averaged 33 months. Patient satisfaction was 6 in the non-workers' compensation group and 4 in the workers' compensation group. Average time to return to work for the non-workers' compensation group was 12 weeks, compared to 37 weeks for the workers' compensation group. Study results indicate that the hypothenar fat pad flap produces excellent results in procedures designed to alleviate recalcitrant idiopathic carpal tunnel syndrome.

Recalcitrant carpal tunnel. The hypothenar fat pad flap.

Open decompression of the median nerve generally is so effective that little is mentioned of the surgical treatment options for recalcitrant or unrelieved carpal tunnel syndrome. The hypothenar fat pad flap has been shown to be a reliable local source of well-vascularized adipose tissue that can be used for coverage of the median nerve during re-exploration of recurrent or persistent idiopathic carpal tunnel syndrome. The hypothenar fat pad flap is a technically simple procedure that allows the fat pad to be mobilized easily and placed across the palm as a barrier between the nerve and the radial leaf of the transverse carpal ligament, effectively preventing median nerve readherence. This flap hopefully will improve the tissue environment for the median nerve, permitting it to have normal excursion during wrist motion. Our results to date have been better than previously described for other techniques. We believe the hypothenar fat pad flap should be considered in the hand surgeon's armamentarium for recalcitrant idiopathic carpal tunnel syndrome.

Medial and lateral epicondylitis in the athlete.

An appropriate diagnosis must be made after carefully excluding all other options in treating the patient with lateral epicondylitis. The majority of these patients will do well with nonsurgical treatment; however, if unresponsive to this regimen, a carefully selected patient will have a successful result with surgical reconstruction (85%-95% of patients). Attention to detail both pre- and postoperatively will help to create a successful result in a disease entity that plagues a large proportion of our athletic population.

The zig-zag deformity in pre-axial polydactyly. A new cause and its treatment.

Most cases of zig-zag deformity following treatment of pre-axial polydactyly have resulted from inadequate reconstruction of bifid bony elements. We report its development after simple suture ligature of the radial component of a bifid thumb in the form of a soft tissue tag at the level of the MP joint. Successful reconstruction has been achieved with the use of similar principles proposed for the more characteristic zig-zag deformity. Parents, paediatricians, and obstetricians should be warned that simple suture ligature of the soft tissue tag may allow the development of a zig-zag deformity and require further reconstruction.