Elan J. Golan

Importance of the posterior bundle of the medial ulnar collateral ligament

BACKGROUND There has been a renewed interest in the pathomechanics of elbow dislocation, with recent literature having suggested that the medial ulnar collateral ligament is more often disrupted in dislocations than the lateral ligamentous complex. The purpose of this serial sectioning study was to determine the influence of the posterior bundle of the medial ulnar collateral ligament (pMUCL) as a stabilizer against elbow dislocation. METHODS An elbow dislocation was simulated in 5 cadaveric elbows by mechanically applying an external rotation moment and valgus force. Medial ulnohumeral joint gapping was measured at 30°, 60°, and 90° of flexion in an intact elbow after sectioning of the medial collateral ligaments anterior bundle (aMUCL) and then after sectioning of the pMUCL as well. RESULTS After sectioning of the aMUCL, the pMUCL was able to stabilize the joint against dislocation. After aMUCL sectioning, the proximal joint space significantly increased by 4.2 ± 0.6 mm at 30° of flexion and 2.6 ± 0.3 mm at 60° of flexion, although it did not dislocate. The gapping increase of 0.9 ± 0.6 at 90° of flexion did not reach significance. After sectioning of the pMUCL (after having already sectioned the aMUCL), all of the specimens frankly dislocated at all flexion angles. CONCLUSIONS An intact pMUCL can prevent elbow dislocation and limited joint subluxation to within 6.6 mm. Our findings indicate that repair or reconstruction may be warranted in certain circumstances (ie, residual instability after operative management of a terrible triad injury or after aMUCL reconstruction).

The Posterior Bundle’s Effect on Posteromedial Elbow Instability After a Transverse Coronoid Fracture: A Biomechanical Study

PURPOSE There has been increased interest in the role of the posterior bundle of the medial collateral ligament (pMUCL) in the elbow, particularly its effects on posteromedial rotatory stability. The ligaments effect in the context of an unfixable coronoid fracture has not been the focus of any study. The purposes of this biomechanical study were to evaluate the stabilizing effect of the pMUCL with a transverse coronoid fracture and to assess the effect of graft reconstruction of the ligament. METHODS We simulated a varus and internal rotatory subluxation in 7 cadaveric elbows at 30°, 60°, and 90° elbow flexion. The amount of ulnar rotation and medial ulnohumeral joint gapping were assessed in the intact elbow after we created a transverse coronoid injury, after we divided the pMUCL, and finally, after we performed a graft reconstruction of the pMUCL. RESULTS At all angles tested, some stability was lost after cutting the pMUCL once the coronoid had been injured, because mean proximal ulnohumeral joint gapping increased afterward by 2.1, 2.2, and 1.3 mm at 90°, 60°, and 30°, respectively. Ulnar internal rotation significantly increased after pMUCL transection at 90°. At 60° and 30° elbow flexion, ulnar rotation increased after resection of the coronoid but not after pMUCL resection. CONCLUSIONS An uninjured pMUCL stabilizes against varus internal rotatory instability in the setting of a transverse coronoid fracture at higher flexion angles. Further research is needed to optimize graft reconstruction of the pMUCL. CLINICAL RELEVANCE The pMUCL is an important secondary stabilizer against posteromedial instability in the coronoid-deficient elbow. In the setting of an unfixable coronoid fracture, the surgeon should examine for posteromedial instability and consider addressing the pMUCL surgically.

The pyramidalis-anterior pubic ligament-adductor longus complex (PLAC) and its role with adductor injuries: a new anatomical concept.

PurposeAdductor longus injuries are complex. The conflict between views in the recent literature and various nineteenth-century anatomy books regarding symphyseal and perisymphyseal anatomy can lead to difficulties in MRI interpretation and treatment decisions. The aim of the study is to systematically investigate the pyramidalis muscle and its anatomical connections with adductor longus and rectus abdominis, to elucidate injury patterns occurring with adductor avulsions.MethodsA layered dissection of the soft tissues of the anterior symphyseal area was performed on seven fresh-frozen male cadavers. The dimensions of the pyramidalis muscle were measured and anatomical connections with adductor longus, rectus abdominis and aponeuroses examined.ResultsThe pyramidalis is the only abdominal muscle anterior to the pubic bone and was found bilaterally in all specimens. It arises from the pubic crest and anterior pubic ligament and attaches to the linea alba on the medial border. The proximal adductor longus attaches to the pubic crest and anterior pubic ligament. The anterior pubic ligament is also a fascial anchor point connecting the lower anterior abdominal aponeurosis and fascia lata. The rectus abdominis, however, is not attached to the adductor longus; its lateral tendon attaches to the cranial border of the pubis; and its slender internal tendon attaches inferiorly to the symphysis with fascia lata and gracilis.ConclusionThe study demonstrates a strong direct connection between the pyramidalis muscle and adductor longus tendon via the anterior pubic ligament, and it introduces the new anatomical concept of the pyramidalis–anterior pubic ligament–adductor longus complex (PLAC). Knowledge of these anatomical relationships should be employed to aid in image interpretation and treatment planning with proximal adductor avulsions. In particular, MRI imaging should be employed for all proximal adductor longus avulsions to assess the integrity of the PLAC.

When in Doubt, Examine the Patient: Commentary on an article by Keith D. Baldwin, Md, Mspt, Mph, et al.

A child with a painful, swollen knee can be a diagnostic challenge and the differential diagnosis includes toxic synovitis and septic arthritis. In the Northeast and Upper Midwest of the United States, one must also include Lyme disease in the differential diagnosis. Differentiating among these three entities can be difficult and their treatments are very different. Toxic synovitis is a diagnosis of exclusion and resolves on its own, but Lyme disease is treated with oral antibiotics. In contrast, the treatment of septic arthritis requires timely open or arthroscopic irrigation and debridement, along with a course of organism-appropriate antibiotics. Currently, there is no quick and accurate test for Lyme disease. The white blood-cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels are helpful, but by themselves are not diagnostic. With the introduction of a diagnostic algorithm based on 4 readily available patient criteria, Kocher et al. helped clinicians to distinguish between toxic synovitis and septic arthritis of the hip. The criteria of Kocher et al. are often employed for the evaluation of other acutely painful joints. However, because Lyme disease was not considered in the study by Kocher et al., the usefulness of their algorithm in distinguishing Lyme disease from septic arthritis is limited at best. Additionally, more traditional markers obliging operative intervention, such as a synovial white blood-cell count of >60,000 cells/mm, have been demonstrated to poorly differentiate between Lyme disease and infectious etiologies of articular disease, further complicating decision-making in the emergency setting. Baldwin et al. introduce a similar set of criteria intended to aid in the diagnosis of monoarticular arthritis in the pediatric knee. Their work constitutes a retrospective review of patients presenting for emergency evaluation of the acutely swollen and painful knee, with a final diagnosis of Lyme disease or infectious arthropathy confirmed by synovial white blood-cell count and on culture, along with the results of Lyme titers. The authors identified 4 patient factors predictive for septic arthritis, with the presence of all 4 factors correlating with a final diagnosis of infectious arthritis in 100% of patients examined. Criteria included a CRP level of >4 mg/L, age of <2 years, history of fever, and pain with short arc motion. In a manner similar to the Kocher criteria, the study also demonstrates an increased likelihood of infection as more factors are identified. Although the proposed algorithm represents a potentially powerful new diagnostic tool, we believe the true contribution of this work to be the authors’ highlighting of pain with short arc motion as the single most reliable predictor of infection. As hands-on physical examination is continually deemphasized in the wake of ever-improving technology and laboratory testing, the current study constitutes a much-needed reminder of the undeniable value of focused clinical assessment. Furthermore, in the pediatric world, where needle-sticks are an infamous cause of discomfort and apprehension, it is refreshing to encounter a diagnostic algorithm whose emphasis is an easily performed physical examination, which we believe to be superior to a laboratory result in many ways. In addition to invoking much less anxiety than a laboratory needle stick, the preferential use of physical examination also has the advantage of being free of cost, easily repeatable, and instantly interpreted. Of course, one could argue that the inclusion of short arc motion is also a weakness of the study, as this finding is subjective and prone to differential interpretation. However, in addition to being previously validated for physical examination, it is our belief that the information resulting from such examination findings can be almost as consistent as any laboratory result, especially for a shrewd practitioner, able to incorporate tactics such as distraction over multiple examinations. This belief is further supported by the fact that, in the current study, pain with short arc motion constituted the single best individual predictor of an infectious diagnosis, suggesting that such examinations, even when performed by multiple clinicians, result in limited variability. e38(1)

The epidemiology of finger dislocations presenting for emergency care within the United States

Background: There are little demographic data on finger dislocation injuries. This study examines the epidemiological characteristics of patients presenting for emergency care of finger dislocations within the United States. Methods: The National Electronic Injury Surveillance System was queried for finger dislocation injuries treated in US emergency departments between 2004 and 2008. Weighted estimates, in conjunction with Census data, were used to analyze patient demographics, injury locales, and incidence rates within and between, demographic groups. Results: During the 5-year study period, an estimated 166 561 finger dislocations were treated in 1 499 222 917 person-years: an incidence rate of 11.11 per 100 000 person-years. Males were predominantly affected (78.7%) at an incidence rate of 17.8 per 100 000. The rate in females was 4.65 per 100 000 person-years. Most dislocations occurred in the 15- to 19-year age group (38.6 dislocations per 100 000 person-years). Among racial groups, blacks (16.8) were affected more than whites (7.72) or patients characterized as “other” (4.90). In terms of injury venue, 35.9% of cases took place at a sporting or recreational facility. In addition, 44.7% of sports-related dislocations occurred while playing either basketball or football. Conclusions: In the United States, finger dislocations appear to occur most often in black males 15 to 19 years of age and among sports participants, particularly basketball and football players.

Obturator Nerve Entrapment

Obturator neuropathy is a rare condition occurring secondary to compression of the anterior branch of the obturator nerve at several different sites of entrapment. The condition most commonly manifests with deficits in medial thigh sensation and adductor musculature strength. Symptoms are often vague due to dual innervation of structures involved in the condition’s pathoanatomy. Diagnosis is often complicated by the many adjacent structures that are prone to other forms of injury. Advanced imaging including MRI and EMG can facilitate accurate identification of obturator pathology. Potential treatments including injection and therapy have been described; however, surgical release is advocated as the consensus method of definitive intervention, especially in the setting of confirmed chronic nerve entrapment.

Utilization and Impact of Social Media in Hand Surgeon Practices

Background: Social media is an effective tool to enhance reputation and brand recognition and is being used by more than 40% of patients when selecting a physician. This study aimed to evaluate the use of social media in hand surgeon practices, and to assess the impact that one’s social media presence has on physician-rating website scores (PRWs). Methods: Randomly selected hand surgeons from across the United States were identified. Sequential searches were performed using the physicians name + the respective social media platform (Facebook, LinkedIn, YouTube, Twitter, Instagram, personal website, group website). A comprehensive social media utilization index (SMI) was created for each surgeon. Utilizing descriptive statistics, we assessed the effect of social media on the PRW. Results: A total of 116 board-certified hand surgeons were included in our study. The sample identified 10.3% of the population used Facebook, 1.7% used Twitter, 25.8% used YouTube, 22.4% used LinkedIn, 27.5% used a personal website, and 36.2% used a group website, 0% used Instagram. The average SMI was 1.53 ± 1.42 (0-6). Physicians with a personal website received higher Healthgrades scores than those without one (P < .05). Analysis of SMI demonstrated that hand surgeons with an index less than 3 received lower Healthgrades scores compared to those with an SMI above 3 (P < .001). Conclusion: Hand surgeons underutilize social media platforms in their practice. A personal website is single most important social media platform to improve HealthGrades score in hand surgeons.

Alterations in Glenohumeral Forces Following Rotator Cuff Injury and Repair

Objectives: Rotator cuff repair is associated with an unusually high incidence of osteoarthritic changes and cartilage damage in the glenohumeral joint. Such degeneration may be secondary to improper tensioning of muscular stabilizers during surgical intervention; however, existing studies have not specifically examined changes in joint congruity following rotator cuff repair. Therefore, the purpose of this study was to assess for changes in glenohumeral contact forces following the repair of rotator cuff injury. Methods: Transduction mapping was performed on the glenohumeral joint of ten fresh-frozen cadaveric shoulder specimens. A calibrated pressure-mapping sensor was introduced through the rotator interval and secured along the concavity of the glenoid labrum. Following a baseline force measurements, analysis of force intensity and total glenohumeral contact area was performed in each specimen for 6 simulated injury and treatment conditions: A) A 1 cm supraspinatus lesion; B) 2-suture repair of the 1 cm lesion; C) removal of the 2-suture repair; D) a 2 cm supraspinatus lesion; E) 3-suture repair of the 2 cm lesion and; F) removal of the 3-suture repair. All repairs were performed via bone tunnels in the standard method described. Data were recorded over 60s intervals at a rate of 4 frames per second and included raw force, area, and force per unit area. Values for lesion, repair, and post-repair conditions were expressed as a proportion of initial baseline measurements. Means and standard deviations were then calculated for each condition and compared via Student’s t-tests. Results: For baseline measurements, the mean intact glenohumeral force was 38.55 ± 24.79 N and the mean contact area was 313 ± 84.09 mm2. In comparison to baseline values, 3-suture repair yielded a significant increase in both total glenohumeral force (mean proportion: 2.16 ± 3.26; p=0.046) as well as proportion of force per unit area (1.73 ± 1.86 N/mm2; p=0.024). Both the 2 cm lesion and the 2-suture repair removal yielded significant decreases in contact area when compared to baseline, with the former exhibiting a proportion of 0.76 ± 0.19 (p=0.040) and the latter yielding a proportion of 0.60 ± 0.29 (p=0.004). No other conditions exhibited significant changes from baseline measurements. Conclusion: Rotator cuff injury leads to alterations in glenohumeral forces, with significant increases in articular contact-pressures following repair of larger supraspinatus lesions. These findings offer a possible explanation for the high rate of degenerative changes demonstrated following rotator cuff repair. Further study is warranted to determine how current treatment methods might be improved to result in glenohumeral contact pressures resembling those experienced prior to injury.

Obesity Is Not a Predictor of Complications in Upper Extremity Surgery

Background: Obesity is an often-cited cause of surgical morbidity. As a result, many institutions have required screening prior to “clearing” obese individuals for surgery. However, it remains unclear whether such testing is warranted for obese patients prior to upper extremity procedures. This study reviews surgical outcomes to determine if obesity does predict operative morbidity following upper extremity surgery. Methods: The National Surgical Quality Improvement Program was queried for 18 Current Procedural Terminology codes, representing upper extremity fracture and arthroplasty procedures. Patients’ body mass index (BMI) and medical histories were examined as predictors for postoperative complications. Both individual and combined incidences of complications were compared between patients stratified as normal-weight (BMI < 30); obese (BMI 30-40); and morbidly obese (BMI> 40). Results: A total of 8,477 patients were identified over the 5-year study period; 5,303 had a BMI <30, 2,565 a BMI of 30 to 40 and 585 a BMI >40. With the exception of postoperative blood transfusions, there were no significant increases in the incidence rates of any complication event as a function of BMI class. The overall incidence of complications was 2.70 % for BMI <30; 2.74 % for BMI 30 to 40; and 1.54 % for BMI >40. Conclusions: Obesity is not a reliable predictor of complications following upper extremity surgery. Thus, requiring preoperative screening for obese patients may constitute an unnecessary burden on medical resources. Further study is needed to identify specific demographics that might serve as more accurate predictors of poor outcomes in obese patients undergoing surgery of the upper extremity.

When in Doubt, Examine the Patient: Commentary on an article by Keith D. Baldwin, Md, Mspt, Mph, et al.: "predictive Factors for Differentiating Between Septic Arthritis and Lyme Disease of the Knee in Children".

A child with a painful, swollen knee can be a diagnostic challenge and the differential diagnosis includes toxic synovitis and septic arthritis. In the Northeast and Upper Midwest of the United States, one must also include Lyme disease in the differential diagnosis. Differentiating among these three entities can be difficult and their treatments are very different. Toxic synovitis is a diagnosis of exclusion and resolves on its own, but Lyme disease is treated with oral antibiotics. In contrast, the treatment of septic arthritis requires timely open or arthroscopic irrigation and debridement, along with a course of organism-appropriate antibiotics. Currently, there is no quick and accurate test for Lyme disease. The white blood-cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels are helpful, but by themselves are not diagnostic. With the introduction of a diagnostic algorithm based on 4 readily available patient criteria, Kocher et al. helped clinicians to distinguish between toxic synovitis and septic arthritis of the hip. The criteria of Kocher et al. are often employed for the evaluation of other acutely painful joints. However, because Lyme disease was not considered in the study by Kocher et al., the usefulness of their algorithm in distinguishing Lyme disease from septic arthritis is limited at best. Additionally, more traditional markers obliging operative intervention, such as a synovial white blood-cell count of >60,000 cells/mm, have been demonstrated to poorly differentiate between Lyme disease and infectious etiologies of articular disease, further complicating decision-making in the emergency setting. Baldwin et al. introduce a similar set of criteria intended to aid in the diagnosis of monoarticular arthritis in the pediatric knee. Their work constitutes a retrospective review of patients presenting for emergency evaluation of the acutely swollen and painful knee, with a final diagnosis of Lyme disease or infectious arthropathy confirmed by synovial white blood-cell count and on culture, along with the results of Lyme titers. The authors identified 4 patient factors predictive for septic arthritis, with the presence of all 4 factors correlating with a final diagnosis of infectious arthritis in 100% of patients examined. Criteria included a CRP level of >4 mg/L, age of <2 years, history of fever, and pain with short arc motion. In a manner similar to the Kocher criteria, the study also demonstrates an increased likelihood of infection as more factors are identified. Although the proposed algorithm represents a potentially powerful new diagnostic tool, we believe the true contribution of this work to be the authors’ highlighting of pain with short arc motion as the single most reliable predictor of infection. As hands-on physical examination is continually deemphasized in the wake of ever-improving technology and laboratory testing, the current study constitutes a much-needed reminder of the undeniable value of focused clinical assessment. Furthermore, in the pediatric world, where needle-sticks are an infamous cause of discomfort and apprehension, it is refreshing to encounter a diagnostic algorithm whose emphasis is an easily performed physical examination, which we believe to be superior to a laboratory result in many ways. In addition to invoking much less anxiety than a laboratory needle stick, the preferential use of physical examination also has the advantage of being free of cost, easily repeatable, and instantly interpreted. Of course, one could argue that the inclusion of short arc motion is also a weakness of the study, as this finding is subjective and prone to differential interpretation. However, in addition to being previously validated for physical examination, it is our belief that the information resulting from such examination findings can be almost as consistent as any laboratory result, especially for a shrewd practitioner, able to incorporate tactics such as distraction over multiple examinations. This belief is further supported by the fact that, in the current study, pain with short arc motion constituted the single best individual predictor of an infectious diagnosis, suggesting that such examinations, even when performed by multiple clinicians, result in limited variability. e38(1)