Gross and histological analysis of healing after dog flexor tendon repair with the Teno Fix device.

The purpose of this study was to examine the in vivo characteristics of the stainless-steel Teno Fix device used for flexor tendon repair. The common flexor digitorum superficialis tendon was transected in 16 dogs and repaired with the device. The animals were euthanized at 3, 6, or 12 weeks postoperatively. Difficulties with cast immobilization led nine of 16 animals to be full weight bearing too early, leading to rupture of their repairs. The seven tendons with successful primary repairs (gap <2mm) underwent histological examination. This in vivo study demonstrates that use of the Teno Fix in "suture" of dog flexor tendons did not lead to scarring at the tendon surface, does not cause an inflammatory reaction within the tendon and does not interfere with tendon healing.

Nerve entrapment in athletes.

Nerve entrapment syndromes can occur in athletes. The repetitive and vigorous use or overuse of the upper extremity makes the athlete particularly vulnerable to disorders of peripheral nerves. Understanding the clinical signs and symptoms is essential to treatment. The pertinent anatomy, clinical presentation, treatment, and rehabilitation necessary for return to sports for various nerve entrapments have been described. This should enable the physician caring for the athlete to help prevent injury and to guide appropriate treatment, if intervention becomes necessary.

Examination of the anatomic relationship of the proximal germinal nail matrix to the extensor tendon insertion.

The purpose of this study was to delineate the relationship of the terminal extensor tendon insertion to the proximal limit of the germinal nail matrix. Sixteen fresh-frozen human cadaver fingers without any evidence of trauma (average age, 55 years; 3 males and 1 female) were used for this study. Under x25 magnification the proximal limit of the germinal nail matrix and the terminal bony insertion of the extensor tendon were identified. The distance from the terminal tendon insertion to the germinal nail matrix was ascertained using precision calipers. The average distance from the terminal extensor tendon insertion to the proximal edge of the germinal nail matrix was found to be 1.2 mm. We conclude that the proximal limit of the germinal matrix is extremely close to the terminal extensor tendon bony insertion. When the extensor tendon insertion is visualized during operative exposures of the dorsum of the distal phalanx, care should be taken to avoid damaging the germinal matrix. Conversely, when the nail bed is being completely excised, visualization of the insertion of the extensor tendon will indicate that further proximal dissection is not required.

Osteoarthritic changes in the biochemical composition of thumb carpometacarpal joint cartilage and correlation with biomechanical properties.

The biochemical composition and biomechanical properties of articular cartilage from 53 human thumb carpometacarpal (CMC) joints from cadavers aged 20 to 79 years were measured and studied in normal, mildly fibrillated, and advanced osteoarthritic (OA) joints. Statistical analyses were performed to determine the correlations between the compositional measures and biomechanical properties. For these CMC joint tissues we found that water content increased, proteoglycan content decreased, and collagen content per dry weight remained unaltered with progression of OA degeneration. We also found that with disease progression, as defined by an OA staging score, the aggregate modulus (ie, compressive stiffness) decreased, along with an unexpected moderate decrease in permeability. This latter finding appears to be specific to CMC cartilage degeneration since articular cartilage from knees and hips generally demonstrates an increase in permeability with water content and OA score. Correlations between biochemical composition and biomechanical properties were found to be stronger in joints with OA than in joints without OA. This finding suggests that OA changes in biochemical composition, relative to baseline normal values, directly affect the biomechanical properties of cartilage, even though the baseline compositional values themselves do not directly determine the magnitude of the biomechanical properties in normal tissue.

Management of acute and chronic biceps tendon rupture.

In conclusion, the authors believe that younger high-demand patients should be offered the option of surgical repair; can be performed through the preferred single anterior incision with two suture anchors. Chronic tears, even with retraction, may be successfully reconstructed using a free tendon graft, often the flexor carpi radialis. Complications, including radial nerve palsy and proximal radioulnar synostosis, can be avoided with the single-incision technique. Older, low-demand patients can be rehabilitated and have excellent function without acute repair. Partial tendon injuries, for the most part, may be treated with rest and rehabilitation and explored only for chronic, unremitting pain. The authors believe that the single anterior approach should be used over the previously popularized two-incision technique.

Thenar insertion of abductor pollicis longus accessory tendons and thumb carpometacarpal osteoarthritis.

Although the etiology of osteoarthritis of the thumb carpometacarpal (CMC) joint remains unclear, some theories have focused on variations in the local anatomy of the abductor pollicis longus tendon insertion. This cadaver study of 68 specimens analyzed the relationship between a thenar insertion of an accessory abductor pollicis longus tendon and the presence and severity of thumb CMC osteoarthritis. The joint cartilage surfaces were visually graded for degenerative changes. Thirty-five of 68 specimens (51%) had a thenar insertion, most frequently inserting on either the abductor pollicis brevis or opponens pollicis fascia or muscle belly. No significant association between a thenar insertion and thumb CMC arthritis was observed. Conversely, increasing age was noted to have a significant association with degenerative joint disease. Thus, these findings indicate that a thenar slip of the abductor pollicis longus tendon does not correlate with the presence or severity of CMC osteoarthritis.

Extensor pollicis longus tenosynovitis: a case report and review of the literature.

A case of tenosynovitis of the extensor pollicis longus, or third dorsal compartment, is presented. This is an unusual condition that may be difficult to diagnose initially. A clinical test for extensor pollicis longus tenosynovitis is described. Operative treatment is recommended.

The assessment and treatment of nerve dysfunction after trauma around the elbow.

Nerve dysfunction after trauma around the elbow can lead to significant long-term pain and functional deficit. Fortunately, most of these injuries are neurapraxias that will recover spontaneously after conservative treatment. The necessity and time frame for surgical intervention for specific patterns of nerve dysfunction remains controversial. Often surgical exploration exacerbates rather than alleviates the presenting nerve problem. Distal humeral shaft fractures, elbow dislocations, Monteggia fracture-dislocations, supracondylar fractures in children, and proximal forearm trauma all have been associated with various types of nerve injuries with a variable degree of recovery. The early recognition of nerve dysfunction combined with appropriate treatment measures is the key to successful outcome.

Treatment of unstable distal radius fractures with cancellous allograft and external fixation.

Unstable fractures of the distal radius continue to pose a challenge to the hand surgeon. Adjunctive bone grafting is often required to augment structural integrity and aid healing. Because of the risks inherent to bone autograft harvest, however, freeze-dried, irradiated cancellous bone allograft has been used to treat unstable distal radius fractures with severe metaphyseal comminution. Seventeen patients with such fractures (mean age, 70 years; 2 males and 15 females) were treated with bone allograft and external fixation with or without internal fixation. The outcome was evaluated using the modified Mayo wrist score, demonstrating 3 excellent, 8 good, 6 fair, and no poor results on follow-up examination (mean follow-up period, 23 months; range, 7-43 months). The patients were requested to return for follow-up review between 1997 and 1998. These results show that cancellous bone allograft is a useful adjunct to external fixation in the treatment of unstable distal radius fractures.

The teres major muscle: an anatomic study of its use as a tendon transfer.

Eleven fresh-frozen cadaver shoulders were dissected to define the anatomy of the teres major muscle and tendon and to determine the muscle's potential for use as a tendon transfer to the humeral head. Of the 11 specimens, 7 had Mathes type II circulation. The primary and secondary pedicles, from the circumflex scapular artery, entered the muscle 4.1 cm and 0.5 cm from the scapula, respectively. The lower subscapular nerve entered 4.1 cm from the scapula. Mean tendon and muscle lengths were 2.0 and 11.8 cm, respectively. As a unipolar transfer, the tendon reached the greater tuberosity in all but 1 specimen. The bipolar transfer offered numerous theoretical possibilities. We believe that the teres major has an appropriate vascular supply and adequate length to make it suitable for tendon transfer to the humeral head.

Physical examination of the elbow.

A carefully executed, thorough physical examination of the elbow will permit reproducible results to be recorded over time. It also provides a working diagnosis or contributes to the determination of a correct diagnosis in a majority of presenting patients.

Biceps and triceps injuries of the elbow.

In this article, the common biceps and triceps injuries about the elbow are reviewed. The relevant anatomy, presenting signs, symptoms, and treatment of these injuries are discussed.

The incidence of ganglion cysts and other variations in anatomy along the course of the suprascapular nerve.

When the diagnosis of suprascapular nerve entrapment syndrome is being considered, variations in anatomy are possible etiologic factors. Seventy-nine shoulders from 41 cadavers were examined for anatomic variations and for ganglion cyst formation in the suprascapular notch, superior transverse scapular ligament, and inferior transverse scapular ligament. The morphologic evaluation of the suprascapular notch revealed a "U" shape in 77% and a "V" shape in 23%, with 89% of cadavers having the same notch shape bilaterally. In 23% of shoulders a variation of the superior transverse scapular ligament was demonstrated such as partial and complete ossification and multiple bands including the first report of a trifid superior transverse scapular ligament. An inferior transverse scapular ligament was observed in only 14% of shoulders. One ganglion cyst was identified, for an incidence of 1%. The mass was located in the supraspinatus fossa adjacent to the superior transverse scapular ligament and appeared to compress and alter the course of the suprascapular nerve. When operative treatment is elected for suprascapular nerve entrapment syndrome and an open surgical approach is undertaken, the location and source of disease and morphologic and anatomic variants must be recognized to ensure adequate access and complete decompression of the suprascapular nerve. The classical description of the superior transverse scapular ligament as a completely nonossified single band should be expected, on average, in approximately three fourths of the cases. Partial or complete ossification and anomalous bands of the superior transverse scapular ligament or a ganglion cyst along the course of the suprascapular nerve may be encountered. Although a superior transverse scapular ligament should be anticipated in all shoulders, an inferior transverse scapular ligament will be a much less frequent finding. The role and significance of suprascapular notch morphologic characteristics warrant further investigation.

Pseudoaneurysm of the ulnar artery occurring after fracture of the distal radius and ulna: a case report.

A case of pseudoaneurysm of the ulnar artery occurring after distal radius and ulna fracture is presented. This case illustrates an uncommon complication following a fairly common injury.

Topography of the osteoarthritic thumb carpometacarpal joint and its variations with regard to gender, age, site, and osteoarthritic stage.

The articular topography of 46 osteoarthritic thumb carpometacarpal joints was quantitatively analyzed, as well as variations with regard to gender, age, site, and anatomic osteoarthritic stage. It was found that for osteoarthritic thumb carpometacarpal joints, (1) the opposing articular surfaces of elder and severely degenerated joints are more congruent than those of middle-aged and minimally or moderately degenerated joints, although the articular contact area is not significantly different when accounting for thinning of the cartilage layer with age or disease; (2) significant changes in joint topography due to osteoarthritis only occur in severely degenerated joints; (3) joints in women are less congruent, have smaller contact areas, and are likely to experience higher contact stresses than joints in men for similar activities of daily living that involve similar joint loads; and (4) osteoarthritic changes are less severe on the dorsoulnar aspect of the trapezium and the dorsal aspect of the metacarpal, which are known to be low load-bearing regions.

Metacarpal shaft fractures: the effect of shortening on the extensor tendon mechanism.

Spiral and oblique metacarpal shaft fractures frequently develop shortening through the fracture site. The acceptable amount of fracture shortening has not been well established. The goal of this study was to elucidate the acceptable limits of metacarpal shaft fracture shortening in a cadaver model by assessing the magnitude of the metacarpophalangeal (MCP) joint extensor lag produced. Nine fresh-frozen cadaver hands were used to create a metacarpal shaft fracture model in the second and fifth metacarpal bones. Sequential shortening up to 10 mm in 2-mm increments was performed. The results revealed an average of 7 degrees of extensor lag at the MCP joint produced for every 2 mm of metacarpal shortening. The capacity of the MCP joint for active hyperextension may compensate for the extensor lag produced by metacarpal shortening in the clinical setting.