Biomechanical Comparison between Volar Plate Fixator and Nonbridge External Wrist Fixator.

Intra-articular distal radius fractures are difficult to reduce and maintain by nonoperative means. ORIF leaves implants in the patient long after the fracture is healed. External fixation can stabilize the reduced fracture and leaves no long-term implants. The nonbridging fixator (NBX) will provide better reduction and comparable rigidity of fixation to a volar plate for a 5-fragment, OTA 23 C3.2 distal radius fracture. A 5-part distal radius fracture was created in 5 pairs of cadaver arms. One arm was randomly fixed with the NBX fixator; the matched pair was fixed with a volar plate (VPS). Fluoroscopic images recorded the extremes of passive volar-dorsiflexion range of motion (ROM) and radial-ulnar deviation ROM. Each arm was loaded with an axial force at a constant displacement rate until failure. The average reduction of radial tilt achieved for the NBX group was 13.8 ± 4.8° and 6.3 ± 4.7° for VPS; radial length: 3.4 ± 3.7 mm for NBX and 1.9 ± 1.0 mm for VPS; volar tilt: 26.3 ± 12.4° for NBX and 14.0 ± 13.5° for VPS. For NBX, ROM was slightly less after fixation than before fracture. ROM with volar plating was greater after fracture. The peak axial load for NBX was 925 ± 445 N; for VPS, 2,152 ± 1023 N. NBX had minimal effect on ROM and provided adequate strength and restoration of alignment at least as good as VPS for this 5-part fracture model.

Free temporoparietal fascial flap for coverage of a large palmar forearm wound after hand replantation.

A free temporoparietal fascial flap with a split-thickness skin graft was used to cover a large palmar forearm wound in a patient whose hand had been replanted 21 days earlier after traumatic amputation at the distal forearm level. At a 39-month follow-up, the patient had achieved an excellent cosmetic and functional result, with no alopecia or facial nerve injury. The flap is advantageous for coverage of wounds that require a large amount of thin, pliable tissue, and it leaves a concealed donor-site scar.

Treatment of severely comminuted intra-articular fractures of the distal end of the radius by open reduction and combined internal and external fixation.

BACKGROUND: Severely comminuted AO type-C3 intra-articular fractures of the distal end of the radius are difficult to treat. Failure to achieve and maintain nearly anatomic restoration can result in pain, instability, and poor function. We report the results of a retrospective study of the use of a standard protocol of open reduction and combined internal and external fixation of these fractures. METHODS: Seventeen of twenty-five patients treated with the protocol were available for follow-up evaluation. Six had an AO type-C3.1 fracture; eight, type-C3.2; and three, type-C3.3. Eleven fractures required a dorsal buttress plate and/or a volar buttress plate, and eleven required bone-grafting. The mean time until the external fixator was removed was seven weeks. RESULTS: At a mean of thirty months postoperatively, the mean arc of flexion-extension was 72% of that on the uninjured side and the mean grip strength was 73% of that on the uninjured side. The mean articular step-off was 1 mm, the total articular incongruity (the gap plus the step-off) averaged 2 mm, and the radial length was restored to a mean of 11 mm. Thirteen patients had less than 3 mm of total articular incongruity. Arthritis was graded as none in three patients, mild in ten, moderate in three, and severe in one. According to the Gartland and Werley demerit-point system, ten of the patients had a good or excellent result. According to the modified Green and O'Brien clinical rating system, five had a good or excellent result. One patient had a fracture collapse requiring wrist fusion, one had reflex sympathetic dystrophy, and three had minor Kirschner-wire-related problems. Total articular incongruity immediately postoperatively had a moderately strong correlation with the outcome as assessed with both clinical rating systems (r = 0.70 and 0.74 for the Gartland and Werley system and the Green and O'Brien system, respectively; p<0.05). CONCLUSIONS: Open reduction and combined internal and external fixation of AO type-C3 fractures can restore radiographic parameters to nearly normal values, maintain reduction throughout the period of fracture-healing, and provide satisfactory functional results.

Articular cartilage nutrition is mediated by subchondral bone: a long-term autograft study in baboons.

OBJECTIVE: To determine the relative importance of subchondral nutrition in cartilage in autologous transplants and its relation to the development of osteoarthritis (OA). METHOD: The study was performed in non-human primates with two types of autografts placed orthotopically. One type of autograft was placed into vascularized, viable cancellous bone well, and another in an identical bone well, but coated with methylmethacrylate. The latter prevented direct contact between the autograft and the host bone. Observations were continued for 3 years. RESULTS: Abrogation of the contact between subchondral bone and articular cartilage-bone autograft had little effect on the cartilage during the first 5-12 months. By 3 years, autografts in the methylmethacrylate wells had non-vascularized and non-viable subchondral bone. The cartilage in these wells underwent degenerative changes compatible with OA. CONCLUSION: Interruption of contact between articular cartilage and vascularized subchondral bone resulted in degeneration of the cartilage. The onset and detection of these degenerative changes required long time periods (3 years). Had the experiments been terminated at 1 year or sooner the above described changes would not be apparent.

Reverse radial forearm fascial flap for soft tissue coverage of hand and forearm wounds.

Six patients with severe hand and forearm injuries involving open wounds and exposed structures were treated with reverse radial forearm fascial flaps and split-thickness skin grafts for soft tissue cover. There were five men and one woman aged between 16 and 36 years. Injuries included soft tissue avulsion on the dorsum of the hand and fingers, extensive flexor and extensor tendon damage, multiple phalangeal fractures, a grade IIIB open dislocation of the index to little carpometacarpal joints, a grade III open metacarpal fracture and a finger amputation. The average wound size was 9 cm in length and 7 cm in width. The mean duration of follow-up was 12 months (range, 5-20 months). All flaps healed well, and all patients were satisfied.

Medical hypnosis and orthopedic hand surgery: pain perception, postoperative recovery, and therapeutic comfort.

Orthopedic hand-surgery patients experience severe pain postoperatively, yet they must engage in painful exercises and wound care shortly after surgery; poor patient involvement may result in loss of function and disfigurement. This study tested a hypnosis intervention designed to reduce pain perception, enhance postsurgical recovery, and facilitate rehabilitation. Using a quasi-experimental research design, 60 hand-surgery patients received either usual treatment or usual treatment plus hypnosis. After controlling for gender, race, and pretreatment scores, the hypnosis group showed significant decreases in measures of perceived pain intensity (PPI), perceived pain affect (PPA), and state anxiety. In addition, physician's ratings of progress were significantly higher for experimental subjects than for controls, and the experimental group had significantly fewer medical complications. These results suggest that a brief hypnosis intervention may reduce orthopedic hand-surgery patients' postsurgical PPI, PPA, and anxiety; decrease comorbidity; and enhance postsurgical recovery and rehabilitation. However, true experimental research designs with other types of controls must be employed to determine more fully the contribution of hypnosis to improved outcome.

Compartment syndromes in obtunded patients.

A high index of suspicion for a compartment syndrome in the upper extremity should be maintained in all obtunded patients who are at risk for the condition. Obtunded patients are those with a dulled or altered physical or mental status secondary to injury, illness, or anesthesia; those with diminished or absent sensation in the upper extremity because of nerve injury or anesthesia; and those whose ability to communicate is impeded, such as infants and young children and the mentally ill or disabled. These patients represent a vulnerable group whose inability to demonstrate the hallmark symptoms and signs of the syndrome puts them in jeopardy of a late diagnosis of a compartment syndrome and its potentially devastating sequelae. The most likely causes of a compartment syndrome in this population are skeletal or soft-tissue trauma, prolonged limb compression, thrombolytic therapy after myocardial infarction, arterial or intravenous fluid administration, and upper extremity Surgery. Whenever a compartment syndrome of the hand, forearm, or upper arm is suspected, the obtunded patient should be examined closely and frequently, and any changes over time should be documented carefully. Intracompartmental pressure measurement provides a useful adjunct to the physical examination and history in these patients and may be diagnostic if other symptoms and signs are obscured. Once the compartment syndrome is diagnosed, emergent fasciotomy is indicated. To avoid a loss of function in the obtunded patient, special care must be taken postoperatively to assure that early motion exercises are carried out.

Compartment syndromes of the hand.

We retrospectively reviewed the records of nineteen patients who had been managed with fasciotomy because of compartment syndrome of the hand. The patients were five months to sixty-seven years old and included ten adults and nine children. Seventeen patients were followed for an average of twenty-one months (range, one to fifty-eight months), one patient was lost to follow-up after discharge, and one patient died four days postoperatively. All of the patients had a tense, swollen hand and elevated pressure in at least one interosseous compartment. Eight patients also had a compartment syndrome of the forearm. The compartment syndromes developed after intravenous injections (eleven patients); after a gunshot wound, a crush injury, or a complication related to the use of an arterial line (two patients each); and after a complication related to an arthrodesis of the wrist or a crush injury due to prolonged pressure on the upper extremity secondary to a drug overdose (one patient each). Fifteen patients had an obtunded sensorium-either because of a serious illness or injury or secondary to prolonged anesthesia-when the compartment syndrome was recognized. In thirteen of these patients, including eight children and five adults, the compartment syndrome developed because of a complication related to the intravenous or intra-arterial administration of drugs. Carpal tunnel release and decompression of the involved compartments led to a satisfactory result for thirteen of the seventeen patients who were followed. The remaining four patients (including two children who had an amputation, one child who had impaired function of the hand secondary to brain damage, and one adult who had extensive involvement of the forearm and complete loss of function of the hand) had a poor result. All four of these patients had been obtunded when the compartment syndrome developed. The treating physician should maintain a high index of suspicion for a compartment syndrome of the hand when managing seriously ill, obtunded patients-particularly children-who are receiving multiple intravenous or intra-arterial injections.

Use of the minicondylar plate in metacarpal and phalangeal fractures.

The minicondylar plate is used for unstable intraarticular and periarticular fractures of the phalanges and metacarpals to provide stability and to allow early motion. This low profile implant can be placed laterally to avoid injury to the extensor mechanism. The authors retrospectively reviewed 53 consecutive patients from 2 institutions in whom 68 fractures (41 metacarpal and 27 phalangeal) had been treated with 1.5-mm or 2-mm minicondylar plates. Common mechanisms of injury were gunshot wounds, crush injuries, and assault/beatings. Thirty-seven fractures were open, 19 had severe soft tissue injury, and 30 required a bone graft. The followup period averaged 17 months. There were no nonunions or malunions. Sixty-seven complications were associated with 40 fractures in 29 patients: primarily symptomatic plates or pullout (30 complications), extensor lag (13 complications), and infections (8 complications). The complication rate was significantly higher in intraarticular and periarticular fractures also involving the middle 1/3 versus proximal 1/3 fractures; open versus closed fractures; fractures with increased soft tissue injury versus minimal injury; and bone grafted versus nongrafted fractures. Final arc of total active motion, available for 45 fractures, was excellent (> or = 221 degrees) for 17 fractures; good/fair (121 degrees to 220 degrees) for 15, and poor (< or = 120 degrees) for 13. Metacarpal fractures had a significantly higher percentage of excellent results than did phalangeal fractures. Final motion did not correlate significantly with complication rate, severity of soft tissue injury, location in the bone, open versus closed fracture, or use of bone graft. When fractures cannot be restored and stabilized reliably by less invasive methods, the minicondylar plate provides secure fixation and can result in adequate function, even in the presence of severe combined injuries.

Precision oblique osteotomy for shortening of the ulna.

The obstacles of prolonged healing time and technically demanding osteotomy and plate fixation in the performance of ulnar shortening osteotomies have been overcome by a precision system that includes a 45 degrees osteotomy and 2.7 mm interfragmentary lag screw. In 23 transverse osteotomies healing time averaged 21 weeks with one nonunion. In 17 precision oblique osteotomies healing time averaged a substantially shorter 11 weeks. Biomechanical data obtained from cadaveric testing comparing these two constructs demonstrated a structural stiffness that was clearly greater in torsion testing for the oblique osteotomy. No biomechanical difference was identified in the anteroposterior and lateral bending tests. The system permits the reliable performance of two parallel osteotomy cuts, allowing the removal of a precise amount of bone. The compression device and specialized plate permit easy coaptation of the osteotomy surfaces, which are locked into position by a precise 22 degrees interfragmentary lag screw. The surgical procedure is more quickly completed, and the frustration of this previously challenging procedure is now completely removed.

Compression plate arthrodesis of the elbow.

We reviewed 15 patients with an arthrodesis of the elbow using an AO compression-plate technique, after an average follow-up of 24 months. The most common indication was an open, infected high-energy injury with associated bone loss. Arthrodesis was successful in all but one patient in whom severe deep infection necessitated amputation. Eight patients were treated with the metal partly exposed in an infected wound. After removal of the metal, all wounds healed secondarily and none had clinical or radiographic signs of sepsis at latest review. Compression-plate arthrodesis of the elbow is a generally applicable method that can be used even in cases of severe bone loss. There appears to be greater certainty of union than with other techniques, and no increased risk of subsequent fracture.

The rheumatoid hand: orthotics as preventative.

The treatment of hand disease in patients with rheumatoid arthritis (RA), with focus on rehabilitation and splinting, is discussed. A review of the data on splinting of hands in RA is included, as is a review of methods for evaluating hand function and staging RA. Recommendations are made for splinting early in the disease course and prior to surgery, rather than late in the course of RA, in an effort to minimize contractures.

Elective discectomy for herniation of a lumbar disc. Additional experience with an objective method.

An objective evaluation for the assessment of patients who have persistent low-back pain and sciatica was tested in eighty-four patients who were operated on by one of us (D.M.S.). In this scoring system, there are four major categories for preoperative assessment: neurological signs, sciatic-tension signs, psychological factors, and imaging studies. When the preoperative scores of the eighty-four patients were correlated with the findings at operation, the three patients who had the lowest scores were the only ones in whom the operative findings were negative. As shown by statistical analysis, the score for imaging studies correlated best with the operative findings. In contrast, in the sixty-one patients who were followed sufficiently to determine the clinical outcome, the psychological score was the best predictor of the outcome of treatment. On the basis of these studies, we concluded that the use of this objective scoring system reduced the incidence of negative findings at exploration of the disc and improved the clinical result after elective discectomy. The higher the score was preoperatively, the more likely the patient was to have a good result after discectomy.