Hadi K. Zein

Trans-fracture transposition of the radial nerve during the open approach of humeral shaft fractures.

The radial nerve constitutes a major problem in humeral shaft fractures; it may be injured immediately or during closed reduction or open reduction and internal fixation with plate and screws. After fixation, the nerve always runs directly over the plate without any interposed structure. If a revision surgery is indicated, the nerve is at high risk as it is usually difficult to dissect from surrounding fibrotic scar tissue or callus formation. To avoid these complications, some authors reported transposition of the radial nerve through the fracture line. We present herein the surgical technique of the trans-fracture transposition of the radial nerve during open reduction and internal fixation of humeral shaft fractures, along with our preliminary results in 6 cases and a review of the literature.

Spontaneous simultaneous bilateral femoral neck fractures secondary to osteomalacia: a case report and review of the literature

We present a case of spontaneous simultaneous bilateral hip fracture in an elderly female patient suffering undiagnosed osteomalacia. She underwent staged bilateral cemented bipolar hemiarthroplasty and received long-term medical treatment for osteomalacia. Our aim is to stress on the clinical value of unexplained chronic bilateral groin pain predicting the occurrence of these fractures and on the importance of evaluating serum levels of vitamin D, calcium and parathyroid hormone especially in elderly sedentary patients with lack of exposure to sunlight.

Fracture of trapezium with trapeziometacarpal subluxation

Fractures of trapezium are reportedly rare, less than 5% of all carpal bones fractures. A vertical sagittal fracture type is encountered in about 20% of cases. This fracture type is unstable and is usually displaced like a Bennett’s fracture. Open reduction and internal fixation is admitted to be the best method of treatment, but it has always been augmented with a postoperative cast immobilization to temporary stabilize the trapeziometacarpal joint. We describe a case of displaced vertical sagittal fracture of the trapezium with trapeziometacarpal subluxation treated by open reduction and internal fixation of the trapezial fracture, associated with temporary stabilization of the trapeziometacarpal joint using two percutaneous intermetacarpal Kirschner wires.

Irreducible volar dislocation of the proximal interphalangeal finger joint

Volar dislocation of the proximal interphalangeal finger joint is rare. The trauma that causes this injury consists in a rotation mechanism in almost all cases. It may be initially missed and diagnosed at a late sequel stage. Closed reduction should always be attempted first but this procedure may result in failure, necessitating a surgical intervention. In irreducible cases, the surgical investigation shows a longitudinal split which separates one of the lateral bands (ulnar or radial) from the central slip of the terminal extensor tendon. In addition, the lateral band is displaced to the volar aspect of the head of the first phalanx, and partially entrapped into the proximal interphalangeal joint, the head of the first phalanx being trapped between the central slip and the displaced lateral band. Surgical relocation of the displaced lateral band gives an immediate reduction of the dislocated joint. We present a case of irreducible dislocation of the proximal interphalangeal joint of the right index finger in a 42-year-old female patient who required a surgical treatment. We present the diagnostic, anatomic and therapeutic aspects of this rare injury, together with a review of the literature.

Ruptures and avulsions of the distal tendon of the triceps brachii

Ruptures and avulsions of the distal triceps tendon are reportedly rare. Various local and systemic conditions have been reported predisposing to rupture. Ruptures may be complete or partial and may occur without or with avulsion of bony fragment from the posterior aspect of the olecranon process. They may easily be missed in acute stage. MRI constitutes a reliable tool for diagnosis as well as to disclose complete and partial forms. Association of triceps ruptures with bony and ligamentous injuries to the elbow has been recently reported. A comprehensive approach treating simultaneously all associated lesions is mandatory. Early surgical repair usually gives satisfactory functional results. Chronic unrepaired complete ruptures lead to serious disability of the elbow function with weak extension strength. This article aims at reviewing the current concepts on this subject.

Avulsion of the distal triceps tendon with fracture of the radial head

We present a rare case of associated distal triceps tendon avulsion with radial head fracture; the lateral and medial collateral ligaments of the elbow were also ruptured. The patient underwent surgical procedure for the reinsertion of the triceps tendon using metallic anchors, radial head prosthetic replacement, and repair of the lateral collateral ligament. We believe this combined injury pattern of radial head fracture with triceps tendon rupture or avulsion should be considered according to the concept of the spectrum of elbow instability.

Transfracture medial transposition of the radial nerve associated with plate fixation of the humerus

PurposeThe aim of this study was to illustrate safety, feasibility and advantages of transfracture medial transposition of the radial nerve during the lateral approach and lateral plating of humeral fractures located in the mid and distal shaft.MethodsThis was a retrospective review and analysis of medical records and radiographs of 19 patients who underwent a transfracture medial transposition of the radial nerve. Fifteen patients were treated for fresh fracture and four for nonunion. All patients were followed up clinically and radiographically for a minimum of 12 months.ResultsPre-operative radial nerve paralysis was present in four patients in the fresh fractures group; post-operative paralysis occurred in two. All patients completely recovered a few months after the index procedure. Except for two, all patients achieved bone healing. One patient from the fresh-fracture group developed nonunion, and one from the nonunion group experienced persistent nonunion; both underwent successful revision surgeries. In addition, four patients with a fresh fracture underwent revision surgery for hardware removal. All but two patients showed no restricted elbow or shoulder joint motion compared with the opposite side.ConclusionTransfracture transposition of the radial nerve during open reduction and internal fixation of humeral shaft fractures is a safe, harmless and feasible procedure when applied for fractures of the middle and distal humeral shaft; it removes the nerve from the surgical field during fracture manipulation and fixation, with a gain in length of the nerve by transforming its course from spiral to straight. Following radial nerve transposition across the fracture, a repeat surgical approach to the humerus for hardware removal or treatment of nonunion transforms the procedure into a simple one; the skin incision is carried straight down to the bone without the need to identify or dissect the nerve that was previously transposed to the medial compartment of the arm.

Kapandji Technique as Aminimally Invasive Procedure for Selected Patients with Two and Three - Part Fractures of the Proximalhumerus

Current algorithms for decision making in proximal humerus fractures consider the fracture pattern along with the patient characteristics and surgeon’s experience. Minimally invasive techniques for reduction and internal fixation of many types of these fractures have recently been widely promoted, especially with the use of the newly developed locking plate systems. Intramedullary flexible nailing is one of the oldest techniques using minimally invasive reduction and fixation of proximal humerus fractures. Kapandji technique uses the “Deltoid V” landmark as entry point for intramedullary insertion of the flexible nails into the humeral head. The authors report their experience with this procedure in twenty-six, relatively young patients with good bone quality, presenting with displaced 2- or 3-part extra-articular fracture of the proximal humerus, treated with percutaneous reduction and intramedullary flexible nailing as described by Kapandji. Nineteen medical records were available for this retrospective review, with 9 to 12 months follow-up. There were 15 excellent and 1 good results when patients were assessed for pain, function and range of motion of the shoulder. The authors submit that Kapandji technique is a valuable procedure for management of extra-articular displaced 2- and 3- part proximal humerus fractures in young patients with good bone quality.

Traumatic posterior shoulder dislocation: a case with modification of Gerber procedure for humeral head reconstruction at 10-year follow-up

We report a case of acute traumatic posterior shoulder dislocation in a 41-year-old patient, which we treated surgically by a modification of the procedure described by Gerber for humeral head reconstruction in such cases. The diagnosis was confirmed by CT scan, which also helped us to assess the size of the antero-medial humeral head defect or impaction secondary to the dislocation; the size of this defect being a determinant element for the indication. Because the shoulder was unstable after closed reduction and almost 50% of the humeral head was impacted, we carried out a surgical treatment using an original technique as mentioned above. Radiologic and surgical features of acute traumatic posterior shoulder dislocation are discussed with special emphasis on diagnosis, indications and surgical aspects of this rare lesion, which represent 2–4% of acute traumatic shoulder dislocations.