David C. Bush

Surgical treatment of displaced olecranon fractures by tension band wiring technique.

Forty-five displaced olecranon fractures including 14 accompanying dislocated radial heads and seven radial head fractures were treated over a 13-year period by the tension band wiring technique. The use of supplemental internal fixation when necessary allows excellent results with the use of this technique, even in the presence of severe comminution or radial head dislocation. Primary silicone radial head implants fractured in all three patients in which they were used, necessitating repeat surgery in two patients to date. While loss of motion in terminal extension was a common aftermath of displaced olecranon fracture (59%), it was usually minor and functionally insignificant. True Kirschner-wire migration was not a common problem and can probably be eliminated by proper technique. The presence of gaps in the intraarticular surface of the semilunar notch of the ulna produced no ill effects and was compatible with excellent results. If only those cases with isolated olecranon fractures in this series are considered, there were good and excellent results in 29 of 30 cases (97%). Excision of the olecranon fragment(s) should be reserved for those cases when anatomic restoration cannot be achieved with internal fixation.

Intraneural steroid injection as a complication in the management of carpal tunnel syndrome. A report of three cases.

Steroid injection can provide symptomatic relief in patients with carpal tunnel syndrome (CTS). Its role should be limited to a diagnostic aid in cases in which symptoms are atypical, a temporizing agent in patients with severe symptoms either who are awaiting surgery or in whom spontaneous remission might be expected, and as a definitive treatment in patients who do not desire surgery. Injection should be performed using proper technique by physicians skilled in carpal tunnel surgery. A soluble preparation of dexamethasone is recommended. Immediate paresthesia in the median nerve distribution or exacerbation of symptoms beyond 48 hours following injection is suspect for inadvertent nerve injury; therefore, early surgical decompression is indicated.

Carpal tunnel syndrome due to tophaceous gout.

Tophaceous gout is a recognized cause of carpal tunnel syndrome. Of 2649 carpal tunnel releases, 15 hands in 13 patients were identified with tophaceous gout in the carpal tunnel. The incidence of tophaceous gout in the carpal tunnel was 0.6%. Twelve of 13 patients were male, and 8 of 10 patients with a history of gout developed carpal tunnel syndrome despite adequate medical treatment. Thus, consideration should be given for tophi as a cause of carpal tunnel syndrome, especially in older men despite medical treatment for gout.

Plant thorn synovitis : an uncommon cause of monoarthritis

Plant thorn synovitis (PTS) is an uncommon cause of monoarthritis. Seven cases of PTS were identified at our institution from January 1979 to July 1990, six of whom were men. Mean age was 27 years (range, 7 to 56 years). Symptoms included pain, swelling, and stiffness. Synovitis was present on examination along with decreased range of motion of affected joints in all patients. Roentgenograms were unremarkable in five patients, but disclosed demineralization in two others. Initial conservative treatment with nonsteroidal antiinflammatory drugs (NSAIDs), antibiotics, or splinting was usually unsuccessful; surgery was necessary in six patients. Findings included marked inflammatory synovial reactions with evidence of retained thorn in all patients. One patient had a positive operative wound culture (Enterobacter agglomerans) without evidence of osteomyelitis. All patients improved after surgery without sequelae. Despite a history suggesting thorn injury in many cases, diagnosis was often delayed; mean time to diagnosis was 10 weeks (range, 2 weeks to 9 months). PTS must be included in the differential diagnosis of monoarthritis. Histologically, PTS can mimic sarcoidosis, tuberculosis, or fungal infection. Optimal treatment of PTS is arthrotomy, foreign body removal, and extensive synovectomy.

Fibroma of tendon sheath in the hand

Seven cases of fibroma of tendon sheath in the hand are reviewed. These tumors are common enough to be considered in the differential diagnosis of a soft tissue tumor in the hand, as they comprised 7 of our series of 208 soft tissue hand tumors excised over a 15-year period. A marginal excision was performed in each case, and no tumor recurred after a mean follow-up interval of 8 years. The fibromas were adherent to tendons, tendon sheaths, and neurovascular structures, and thus were more difficult to excise without morbidity than other soft tissue hand tumors.

Flexor tendon rupture associated with an anomalous muscle

A rupture occurred in the substance of an apparently normal flexor digitorum profundus tendon of a left small finger. It was associated with a previously undescribed anomalous flexor digitorum superficialis of the brevis type to the same finger. Clinical reports of 20 anomalous flexor digitorum superficialis muscles were found in the literature; all but one were on the right side or bilateral and occurred predominantly in females. Three cases were of the brevis type and all involved the index finger. Although the precise reason for rupture is not known we have speculated that the anomalous superficialis may have given rise to a deficient vinculum longus to the profundus predisposing it to failure.

Acute calcific tendinitis in a child: A case report

Abstract Acute calcific tendinitis is an uncommon condition in which soft tissue calcification is associated with an acute inflammatory reaction that may be confused with an infection. Cohen 1 first described a case of acute calcium deposition at the insertion of the flexor carpi ulnaris in 1924. The condition usually occurs in the adult shoulder, wrist, hand, and, on rare occasions, lower extremity. To our knowledge, there is only one reported case of acute calcific tendinitis in a child. 2 This entity is so rare in children that it may not be considered when one is evaluating a child with a suspected infection.

Epidermoid cysts in the hand

This study details our series of epidermoid cysts in the hand, characterising the incidence, clinical characteristics and recurrence rate after marginal excision. A historical cohort of 101 epidermoid cysts that were excised from a soft tissue or intraosseous location in the hand over a 27 year period were reviewed. The incidence of epidermoid cysts, patient age, sex, occupation, anatomic location, history of trauma, treatment complications and cyst recurrence rate were noted. Key findings of the study were as follows. Epidermoid cysts represented a significant portion of our relatively large series of hand tumours. The majority occurred in male patients, most often involving the soft tissues on the palmar aspect of the hand. Four percent were intraosseous epidermoid cysts. After excision with a marginal tumour margin we found that 11 cysts (11%) recurred.

Silicone synovitis: longer term outcome data and review of the literature.

Background:Silicone had been popular for small and medium joint prostheses from the 1960s until the 1980s when concerns about subsequent arthritis arose. There are still patients with long-standing silicone prostheses. We describe 7 cases of synovitis attributed to these. Methods:This is a case series of patients having synovitis in the vicinity of a silicone arthroplasty. The diagnosis was determined by examination and, radiographic and operative characteristics of the joint. Underlying diseases of the patients, treatment strategies, and responses to treatment were reviewed. Results:Seven charts were reviewed. The ages ranged from 53 to 90 years (mean = 71.5). Two patients had osteoarthritis, 1 had rheumatoid arthritis, 3 had trauma, and 1 had avascular necrosis. Joints included 2 metatarsal phalangeal, 3 carpal bones, 1 radial head, and 2 first carpal metacarpals. The time from arthroplasty to synovitis was 9 to 30 years (mean = 16). Five patients had surgical management and 2 had medical management. Four of the surgically managed patients had resolution of their symptoms, 1 had a recurrent synovitis requiring further surgery. One person had 2 arthroplasties, but developed synovitis at only 1 site. The 2 patients medically managed continued to have synovitis. Conclusions:Synovitis continues to be a consequence of silicone arthroplasty. It can be a late complication with our shortest time to synovitis being 9 years. Underlying pathology does not seem to predict the synovitis as patients with osteoarthritis, rheumatoid arthritis, avascular necrosis, and trauma are all represented. Surgically managed patients did well, whereas patients managed medically did not have resolution of their symptoms.

Suppurative extensor tenosynovitis caused by Staphylococcus aureus

Suppurative tenosynovitis is a rare infection, occurring almost exclusively in the flexor tendon sheath as a posttraumatic event. We report the case of a systemically ill woman with suppurative tenosynovitis of the extensor tendons caused by Staphylococcus aureus. Early recognition of this unusual infection may prevent unnecessary morbidity.