Angela A. Wang

The proximal ulna: an anatomic study with relevance to olecranon osteotomy and fracture fixation

The purpose of this study was to define the proximal ulna anatomy with respect to olecranon osteotomy and fracture fixation. Thirty-nine cadaver elbows were dissected. The mean ulnar length (triceps insertion to ulnar styloid) was 26.0 cm (range, 27.1-29.0 cm). The mean distance from the triceps insertion to the ulnas varus angulation point was 7.6 cm (range, 6.5-9.0 cm). The distance ratio from the triceps insertion to the proximal ulnar angle to the overall ulna length was consistent, averaging 0.29 (range, 0.23-0.33). The mean diameter of the medullary canal at the ulnar angulation point could accommodate a 7.0- or 7.3-mm intramedullary screw. The mean width of the olecranon bare area (lacking articular cartilage) was 0.53 cm (range, 0.13-0.97 cm), and the mean distance from the triceps insertion to the corresponding area of the bare spot on the dorsal cortex was 2.1 cm (range, 1.4-2.5 cm).

Bilateral simultaneous open carpal tunnel release: a prospective study of postoperative activities of daily living and patient satisfaction

PURPOSE The purpose of this study was to determine patient function and satisfaction prospectively after bilateral simultaneous open carpal tunnel release (CTR). METHODS Twenty patients (40 CTR) completed a questionnaire regarding postoperative activities of daily living (ADL), return to work, procedure satisfaction (visual analog scale), and willingness to have the surgery again. RESULTS The average patient age was 43 years (range, 23-73 y). The hardest task was opening a jar; the easiest task was using the bathroom. Other tasks on the list in descending order of difficulty included driving, household chores, carrying groceries, buttoning, bathing, cooking, writing, dressing, shopping, holding a book, eating, computer use, and holding a phone. Average return to work was 2.6 weeks (range, 3 d-6 wk). Average satisfaction with the surgery was 9.6 of 10 (range, 8-10); 20 of 20 patients (100%) would have the bilateral simultaneous surgery again. CONCLUSIONS These data are useful for patient education and decision making when considering surgery in patients with bilateral carpal tunnel syndrome, and show that bilateral simultaneous open CTR is a feasible and useful procedure.

The Importance of Shoulder External Rotation in Activities of Daily Living: Improving Outcomes in Traumatic Brachial Plexus Palsy

PURPOSE To define the importance of shoulder external rotation in activities of daily living in normal individuals to better understand how restoration of shoulder external rotation in traumatic brachial plexus palsy could improve patient function. METHODS Thirty-one normal individuals performed 12 common activities of daily living (ADLs) wearing a custom shoulder orthosis designed to selectively limit shoulder external rotation to 3 different settings, ranging from 0° (most restrictive) to 90° (least restrictive) of external rotation. Outcomes were measured with a visual analog scale of perceived difficulty in accomplishing the ADLs with each orthosis setting and the Disabilities of the Arm, Shoulder, and Hand questionnaire administered after each set of 12 ADLs was completed. RESULTS Subjects perceived increasing difficulty during all ADLs tested and registered higher disability scores with increasing restriction of shoulder external rotation. The ADLs requiring motions predominantly above the waist exhibited more marked and earlier changes in visual analog scale scores with increasing shoulder external rotation restriction. CONCLUSIONS Traditionally, surgeons have pursued restoration of shoulder abduction and forward elevation in secondary reconstruction of traumatic brachial plexus injuries. Recently, the concept of preferentially restoring shoulder external rotation has been proposed, without clear evidence in the literature of the role of shoulder external rotation in ADLs. CLINICAL RELEVANCE Our results support the notion that restoring shoulder external rotation in the treatment of traumatic brachial plexus palsy patients might improve outcomes by decreasing patient disability and increasing the ability to perform ADLs.

Full-thickness skin necrosis of the fingertip after application of superglue

We present the case of a 39-year-old woman who applied superglue to her fingertip as a treatment for dry skin. She developed full-thickness necrosis of her thumb pad complicated by a secondary superinfection. This necrosis occurred from the degradation of the cyanoacrylate in the superglue compound to formaldehyde, causing local histotoxicity. This injury necessitated a local flap for coverage, which healed uneventfully and without lasting sequelae.

Late Deformities Following the Transfer of the Flexor Carpi Ulnaris to the Extensor Carpi Radialis Brevis in Children With Cerebral Palsy

PURPOSE The transfer of flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) (the Green transfer) in children with cerebral palsy (CP) is a surgical option frequently used to address the typical wrist flexion deformity that is often present in these patients. We hypothesize that late deformities may occur when these transfers are performed in patients before skeletal maturity. The purpose of this investigation was to determine the frequency of these deformities and the factors that influence their development. METHODS We performed 41 FCU to ECRB tendon transfers in children with CP at our institution between 1987 and 2005 and retrospectively reviewed them. A total of 24 patients with 25 transfers had a minimum 2-year follow-up and were included in the study population. We identified patients who developed a late deformity after tendon transfer. We analyzed medical records of these patients to identify factors associated with the development of a deformity. RESULTS Of the 25 transfers, 12 developed a late deformity between 10 and 105 months postoperatively. The deformities that developed were extension deformities (8), supination deformities (one), and recurrent flexion deformities (3). Of the 12 patients with deformity, 9 required revision surgeries. Of these 12 patients, 9 who were less than 13 years of age at the time of transfer developed a late deformity, compared with 3 who were older than 13 years of age. CONCLUSIONS The FCU to ECRB tendon transfer remains a viable option to address the wrist flexion deformity seen in patients with CP. Care should be taken when performing this tendon transfer in patients less than 13 years of age because they may develop a postoperative deformity, commonly an extension deformity. We believe that these deformities develop when the patient enters a growth spurt and the transferred muscle-tendon unit does not lengthen at the same rate as the involved upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Use of the elbow compass universal hinge in pediatric patients.

The purpose of this study was to review the Compass Universal Hinge dynamic elbow external fixator in pediatric conditions. Eight patients with diagnoses of ulnar club hand (n = 2), proximal radial synostosis with hypoplastic coronoid (n = 1), pterygium cubitale (n = 2), and elbow arthrofibrosis (n = 3) were identified. Indications for fixator placement were to maintain elbow stability during forearm lengthening (two cases), protect a coronoid reconstruction (one case), increase range of motion via the fixator (two cases), and maintain stability and increase range of motion after open release (three cases). There were five boys and three girls with an average age at surgery of 11.5 (range 3-19) years. In each case, the goal for fixator use was achieved: both forearm lengthenings were completed without elbow instability, the coronoid reconstruction healed in good position, and four of five patients obtained increased range of motion via the fixator (average improved arc of motion of 31 degrees), with all elbows remaining reduced and stable. Complications included four pin tract infections, one of which became osteomyelitis; two broken/loose pins; and two cases of decreased elbow range of motion. Average follow-up was 29 (range 3-62) months. Use of the Compass Universal Hinge dynamic external fixator can be adapted to children and has proven useful in managing certain difficult conditions.

Releasing the Tourniquet in Carpal Tunnel Surgery

The purpose of this study was to determine if letting down the tourniquet prior to closure after carpal tunnel release decreases the amount of post-operative ecchymosis and subsequent post-operative pain. We prospectively studied 18 consecutive patients who were undergoing bilateral open carpal tunnel releases. The side done first was randomized and the tourniquet was released to obtain hemostasis prior to closure on this side only. The second side was completed, closed, and dressed prior to letting the tourniquet down. The patients’ pre-operative and post-operative pain scores were recorded, as was an ecchymosis score at the 10-day follow-up visit. The results showed no significant difference between the two groups in either pain or ecchymosis. We conclude that the added surgical time required for letting the tourniquet down and obtaining hemostasis prior to closure in a carpal tunnel is unnecessary.

Management of the Flail Elbow

Flail elbow is a relatively uncommon cause of elbow dysfunction. It is defined as the inability to position the arm in space for useful elbow function because of structural or neurologic inadequacies. Patient function is often severely compromised and treatment options are limited with moderate levels of success depending on etiology. This article reviews the various etiologies of dysfunctional elbow instability, their treatment options, and their expected outcomes.

Results of Treatment of Delta Triphalangeal Thumbs by Excision of the Extra Phalanx.

Background: We examined the long-term results of treatment of delta triphalangeal thumbs by excision of the delta ossicle alone with respect to range of motion (ROM), pain, and angulation at the interphalangeal (IP) joint. Methods: We retrospectively reviewed charts to identify patients who had Woods type I delta triphalangeal thumbs and underwent treatment by excision of the extra ossicle. Patients with >2 years’ follow-up were then brought in for examination and radiographs. Results: We identified 21 thumbs in 14 patients. All patients with bilateral thumb involvement, except 1, had them treated at the same surgery. The average age at surgery was 22 months (range, 5 to 69 mo). Preoperatively, 2 patients had tip radial angulation, averaging 53 degrees. The other 19 thumbs were deviated tip ulnarly with an average preoperative angulation of 40 degrees (range, 20 to 85 degrees). All patients had pinning of the IP joint for an average of 4.5 weeks (range, 3 to 9 wk), and 14 thumbs had collateral ligament repair. We obtained follow-up data >2 years on 14 thumbs in 10 patients. The average follow-up was 6.7 years (range, 2 to 17 y). Average ROM at final follow-up was <−4-degree extension (range, −20 to 0 degrees) to 56-degree flexion (range, 30 to 82 degrees). Average clinical angulation was <1 degree (range, 0 to 10 degrees) and the average radiographic angulation was 7 degrees (range, 0 to 25 degrees). No degenerative changes were noted. There were no complaints of pain and 1 patient had persistent IP instability. No other surgeries had been performed on the affected thumbs and there were no other complications. Conclusions: Delta triphalangeal thumbs treated by excision of the extra ossicle can be expected to yield good long-lasting results with acceptable thumb IP ROM and no pain. Clinical appearance of the thumb with regard to angulation tends to be superior to radiographic findings. We prefer this method in treating Woods type I delta triphalangeal thumbs. Level of Evidence: IV.