Avrum I. Froimson

Ulnar nerve decompression with medial epicondylectomy for neuropathy at the elbow.

Ulnar nerve decompression with medial epicondylectomy was performed in 66 elbows between 1966 and 1986 for compressive ulnar neuropathy at the elbow. This study is an updated review that adds 36 cases to a previously published report on 30 cases. These elbows were graded preoperatively and postoperatively using McGowans grading system. Eighty-three percent improved one or two grades, and 11% improved subjectively although they showed no objective improvement, 3% noted no change, and 3% were subjectively worse. One early case sustained damage to the ulnar collateral ligament with resultant instability. No other complications occurred. The best results were seen in the Grade I and II lesions, whereas those with Grade III lesions were the least predictable. The procedure is technically uncomplicated with minimal morbidity and reliable results.

Treatment of compression neuropathy of the ulnar nerve at the elbow by epicondylectomy and neurolysis

Compression neuropathy of the ulnar nerve at the elbow is treated by neurolysis and excision of the medial humeral epicondyle without transposing the ulnar nerve anteriorly. Removal of the medial humeral epicondyle is not associated with loss of motion at the elbow or reduction in strength of finger or wrist flexion because of the multiple muscle origins, as well as the firm healing of the common flexor origin to the resected bone surface. Thirty cases were treated between 1965 and 1977. Treatment halted progression of the disease in all patients. Discomfort and pain subsided in every instance. All 12 of the grade I patients had return of normal nerve function. Four of the 12 grade II patients were left with some weakness. Four of the six grade III patients improved to grade II status. None required secondary procedures on the ulnar nerve.

A comparison of the disassociation strength of modular acetabular components.

Five short-term in vivo disassembly of two-piece acetabular cup designs have been reported. This study evaluates the liner retention strengths of eight contemporary cup systems. Both push-out (663 +/- 65.5 pounds force to 29 +/- 1.4 pounds force) and lever-out (684 +/- 114 inch-pounds to 43 +/- 1.5 inch-pounds) test modes show a wide variation in retention strength. Repeat liner separation testing demonstrates a 26% and 32% respective decrease in locking mechanism integrity. These findings indicate that reseating modular liners at the time of surgery or reassembling a previously separated liner should be avoided.

Splint immobilization of gamekeeper's thumb

Thirty-nine patients diagnosed with 40 acute complete ruptures of the ulnar collateral ligament of the thumb metacarpophalangeal joint were treated primarily with thumb spica splint immobilization. Duration of splinting ranged from 8 to 12 weeks. Thirty-four of these injuries (85%) followed for 1 to 5 years (average 2.4 years) healed without significant instability, arthrosis, pain, or stiffness (range of motion within 80% of the contralateral hand). Six ruptures (15%) demonstrated persistent instability and pain at 12 weeks and were treated with surgical reconstruction. Currently accepted guidelines for surgical intervention as primary treatment for ligamentous disruption at the thumb metacarpophalangeal joint may need revision. This study suggests that splint immobilization is an effective primary treatment modality. The minority of patients who demonstrate persistent laxity can be successfully treated surgically with excellent results.

Digital lengthening using the callotasis technique.

A series of 14 lengthenings for congenital and posttraumatic digital deficiency has been carried out in a single stage utilizing individual, half-frame design, digital lengthening devices. These devices have afforded individual digital stability without need for additional external support and have provided between 2.0 cm and 3.5 cm lengthening per digit. In only one case was additional bone grafting necessary and in all cases the projected goal of lengthening was achieved. A slow rate of lengthening (0.25 mm in four daily increments) was associated with a minimal amount of pain, patients were able to utilize their hand for function during the lengthening period, and, in cases where physeal plates have remained open, continued growth has been experienced in the follow-up period.

Biomechanical analysis of pin placement and pin size for external fixation of distal radius fractures

A series of biomechanical analyses were performed to explain the recent reduction in treatment-related complications of external fixation of distal radius fractures using a limited open approach for pin placement and larger 4-mm self-tapping half pins. A comparison of pull-out strength, stress concentration effect, and inherent bending strength of 3− and 4-mm half pins was performed. The effect of proximal pin placement in the radius or in the ulna and the effect of distal pin placement in four, six, or eight metacarpal cortices were determined. These analyses demonstrate that the 4-mm self-tapping half pins result in a significantly higher pull-out strength and only a small decrease in torsional load strength of the bone. They also demonstrate that proximal pin fixation in the radius produces the most stable fixation and that distal pin fixation into six metacarpal cortices produces a strong configuration that does not violate the interosseous muscles of the second intrinsic compartment. The rate of treatment-related complications in the external fixation of distal radius fractures (specifically, pin loosening, bending and breakage, fracture through pin sites, collapse at the fracture site, and intrinsic contracture) are addressed in this study. Such complications can be minimized by using 4-mm pins after central predrilling, with proximal placement in the radius and distal placement through six cortices of the bases of the second and third metacarpals.

Compression arthrodesis of the small joints of the hand.

A number of techniques for achieving small joint arthrodesis in the hand combine various forms of internal fixation with external cast or splint immobilization. Rates of arthrodesis in most cases are quite high. However, the prolonged period of adjacent joint immobilization from casting can extend rehabilitation time and limit hand function during healing. Compression arthrodesis has been used effectively in a number of larger joints, such as the knee and ankle. Miniaturization of existing external fixation compression devices now enables the application of this principle to the small joints of the hand. A series of 20 metacarpophalangeal and interphalangeal joints underwent arthrodesis in which a miniature external fixation/compression frame was used. Nineteen of 20 joints demonstrated complete primary arthrodesis within 6 weeks; one fibrous union developed in a distal interphalangeal joint and no postoperative deformities occurred. Complete stabilization was provided by the fixator, thus allowing immediate postoperative adjacent joint function.

Neurogenic arthropathy of the hand and wrist

A case of a variant of congenital indifference to pain, in which the patient initially developed lower extremity neurogenic arthropathy ultimately requiring bilateral above-the-knee amputations, is presented. After he began using his upper extremities for weight bearing and load bearing, the patient developed bilateral severe neurogenic arthropathy of his hands and wrists.

Reversible vasospasm in association with the use of heparin and dihydroergotamine.

A case of reversible vasospasm is reported in a 54-year-old man with a closed bimalleolar ankle fracture. On admission the patient had normal distal pulses and laboratory studies. He was a heavy smoker who continued to smoke in the hospital. Deep venous thrombosis (DVT) prophylaxis included dihydroergotamine and heparin (DHE-H). In the early postoperative period, marked spasm of all three arteries developed on the operative side. Smoking privileges and DHE-H were discontinued. The vasospasm resolved after intraarterial nitroglycerin. This case suggests an infrequent but potentially limb-threatening complication of DHE-H.

Tethered Thumb Sign: A Unique Observation in the Physical Examination of de Quervain Tenosynovitis

To the Editor: Stenosing tenosynovitis of the first dorsal compartment of the wrist is a painful condition that we see frequently. Because radial-sided wrist pain can be attributed to pathologies outside the first compartment, the clinician should ensure that an accurate assessment of the upper extremity is performed to confirm the diagnosis and guide appropriate treatment. A key examination tool is the maneuver characterized by Eichoff and Finklestein, in which the patient clenches the thumb in the palm while the wrist is moved into ulnar deviation. This test can be quite painful at times. Thus, we advise first using an adjunctive tool developed by the senior author (A.I.F.). This proposed maneuver elicits a characteristic response in many of the patients who have de Quervain tenosynovitis. The patient places his or her hands onto the table in a resting position. The clinician then grasps the fingers and brings both wrists into gentle ulnar deviation, allowing the thumb to remain free. In absence of pathology, the thumb follows the cascade of the rest of the hand into ulnar deviation. However, if there is stenosis of the first dorsal compartment, the thumb is tethered and remains aligned with the forearm while the rest of the hand falls into ulnar deviation (Fig. 1). We liken the finding of a tethered thumb to an accentuated tenodesis effect of the extensor pollicis brevis and abductor pollicis longus tendons, leading to the fixed position of the thumb with passive wrist ulnar deviation. We believe that this clinical maneuver can support the diagnosis of de Quervain tenosynovitis and assist in determin-