Carl R. Coleman

Fracture of the tibial tubercle

Tibial tubercle fractures are uncommon and rarely occur after closure of the proximal tibial epiphysis. A study of 15 such injuries, all unilateral, showed the age range to be from 12 to 16 years. All injuries were sustained during athletic activities or vigorous play. All of the 15 injuries were treated by open reduction and internal fixation, followed by plaster immobilization for approximately 6 weeks. No early complications occurred, and no later deformities, such as genu recur vatum as reported by Blout, were de tected. All patients returned to normal activity including, in some cases, varsity athletics.

A standardized measurement of ulnar carpal translocation

45 seconds without severe pain recurring and pinch strength falling again to 10 pounds (Fig. 1). Diagnosis of a chronic, exercise-induced, compartment syndrome in the first dorsal interosseous muscle was made. The patient had a release of the fascia of the first dorsal interosseous muscle and of the adductor pollicis through a 1% cm, V-shaped incision made in the first dorsal web space under local anesthesia. By 2 weeks after surgery, he could pinch repetitively without the aching discomfort (Fig. 1). He was placed on gentle pinching exercises in the immediate postoperative period to permit stretching of the fascial compartments. By 1 month after surgery, he was able to work without problems. Two months later, the opposite hand had a similar procedure.

Long-term results of the minimal resection Darrach procedure

Eighteen patients had a minimal resection Darrach procedure at the distal radial-ulnar joint for treatment of posttraumatic arthritis. The follow-up averaged 8 years (range, 2 to 18 years). Fourteen patients were completely satisfied with the result achieved with the procedure and four were mostly satisfied. No patient had either subjective or objective evidence of distal ulnar instability. Grip strength for patients without radiocarpal arthritis was 84% of the uninvolved side. Preoperative ulnar variance was plus 4 mm and at follow-up minus 4 mm. At follow-up examination, four patients had ulnar carpal translocation. The average radial inclination angle of the patients with ulnar carpal translocation was 24 degrees, compared with 18 degrees for patients without ulnar carpal translocation. The minimal resection Darrach procedure gives excellent relief of pain without the instability attributed to the Darrach procedure. It must be used judiciously in patients who have a radial inclination angle above 23 degrees.

Suspected scaphoid fractures in skeletally immature patients: application of MRI.

PURPOSE The purpose of our study was to evaluate the MR findings in the wrists of pediatric patients who have sustained acute wrist injuries and to determine if this imaging method yields more information than combined serial radiographs and physical examinations. METHOD Eighteen skeletally immature patients (11 boys and 7 girls, age range 8-15 years) who had presented to the emergency room within 2 days following acute wrist trauma underwent serial clinical, radiographic, and MR examinations if there was a suspicion of a scaphoid fracture. RESULTS Ten patients had a scaphoid abnormality on MR images. Six had fractures and four had regional bone marrow edema. Initially, all but two fractures were radiographically occult, although the other fractures eventually became evident on later studies. Those with marrow edema did not progress to fractures. Obliteration of the scaphoid fat stripe occurred in five patients with a scaphoid fracture and in six patients who did not have a fracture. Dorsal soft tissue swelling occurred in eight patients, five of whom had scaphoid fractures. Seven patients had evidence of extensor tenosynovitis on MRI. CONCLUSION A normal initial MR image had a negative predictive value of 100%. Persistent snuffbox pain may represent injury to the scaphoid, extensor tendons, or dorsal soft tissues. An outcome study evaluating the benefits of early application of MR in the pediatric population is warranted.

Madelung Deformity in Skeletally Immature Patients: Morphologic Assessment Using Radiography, Ct, and Mri

PURPOSE The purpose of this study was to define the pathoanatomy of the distal radius and surrounding soft tissues, identify the factors that may contribute to diminished forearm rotation, and relate these findings to alterations in wrist motion in skeletally immature patients with the Madelung deformity. METHOD Four skeletally immature female patients with bilateral Madelung deformities (eight wrists) underwent evaluation of each wrist with radiography, CT, and MRI to assess the morphology of the deformity. Two patients (four wrists) had isolated idiopathic Madelung deformities, and two patients (four wrists) had Madelung deformities secondary to dyschondrosteosis. RESULTS Radiographically, all wrists demonstrated dorsal bowing of the radius, marked ulnar tilting of the radius and radial tilting of the ulna, volar tilting of the distal articular surface of the radius, and triangulation of the epiphysis. On CT, patients with the idiopathic deformity demonstrated dorsal ulnar subluxation and relative supination of the carpus with respect to the distal radius. Patients with dyschondrosteosis demonstrated no ulnar subluxation and relative pronation of the carpus. All wrists demonstrated a fixed pronated deformity of the distal radius. On MRI, a physeal bar that bridged the distal metaphysis of the radius to the epiphysis was identified in all eight wrists, located on the volar aspect of the radius at the lunate facet. An anomalous volar ligament, a volar radiotriquetral ligament, and the short radiolunate ligament were hypertrophied in seven wrists. CONCLUSION Based on its location, it is likely that a physeal bar impedes the normal development of the distal radius ulnarly. Hypertrophy of the short radiolunate ligament may be an important contributing factor to carpal pyramidalization owing to tethering on the volar pole of the lunate. Diminished forearm rotation is likely related to carpal malalignment, a fixed pronated deformity of the distal radius, and dorsal bowing of the radius.

Quantification of error in measurement of radial inclination angle and radial-carpal distance

Posteroanterior wrist radiographs of eight patients were evaluated by eight orthopedists. Radial inclination angle and radial-carpal distance were measured by use of a standardized technique. The standard deviation for radial inclination angle was 2 degrees. The standard deviation for radial-carpal distance was 1 mm. The measured rotational variation of radial inclination and radial-carpal distance is 1 degree and 1 mm, respectively, through a 10-degree arc of supination and pronation.

Sequelae of experimental dislocation of a weight-bearing ball- and socket joint in a young growing animal; gross alterations in bone and cartilage.

As a consequence of experimental dislocation of the hip in puppies three to five weeks old, the following changes were observed: (1) acetabular dysplasia as early as four weeks following dislocation; (2) progressive dysplasia to the point of an unrecognizable acetabulum at the time of maturity; (3) nornmal acetabular development following experimental dislocation and immediate relocation: (4) pronounced changes in the head and neck of the femur, manifested by varus deformity of the neck, flattening of the head, and some reduction in the angle of anteversion of the neck; and (5) no abnormalities in the head and neck in the dislocated hips in which the femora were relocated.

Relationship between radial inclination angle and ulnar deviation of the fingers

Fifty wrists (thirty-two patients) with rheumatoid arthritis and ulnar drift of the fingers were examined radiologically and compared to fifty normal wrists radiographs. Statistically significant differences were found for measurements of radial inclination angle, carpal-radial distance, third metacarpal-phalangeal angle, and carpal height ratio. Third metacarpal-phalangeal angle of ten degrees or greater on standard posteroanterior radiograph appears to accurately represent digital ulnar drift. Elevated radial inclination angle was highly correlated with digital ulnar drift (p much less than 0.001). Radial inclination angle greater than twenty-two degrees is associated with the development of digital ulnar drift through two mechanisms, radial carpal rotation, and ulnar carpal translocation.

Connective tissue nevus and osteopoikilosis in the hand: The Buschke-Ollendorff syndrome

The Buschke-Ollendorff syndrome is a rare disorder of uncertain etiology characterized by osteopoikilosis and connective tissue nevi. An unusual presentation of this syndrome is described that involves both the cutaneous and skeletal manifestations affecting the hand. The bones of the hand and carpus are a common site for osteopoikilosis. Connective tissue nevi of the hand may require excision for diagnosis or mechanical impingement. Special elastin stains must be done on these cutaneous lesions to confirm the diagnosis. Routine hematoxylin-eosin stains may fail to show any pathologic change in mild cases.

Principles in the Application of the Hoffmann® Apparatus for Complex Injuries of the Upper Extremity

Fifteen patients with 13 closed and 13 open fractures in the upper extremity were treated with either the Hoffmann apparatus alone or a combination of internal and external fixation. Two patients required amputation for unreconstructable defects. Two asymptomatic nonunions of the distal ulna and one malunion of the distal radius occurred. There were no cases of osteomyelitis at the fracture sites or pin sites. Successful fracture healing in severe injuries was achieved by closely following the principles of fixation for primary or secondary bone healing, with early bone grafting for any osseous deficit and open wound treatment of contaminated fractures.