Hill Hastings

Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures

A new plate designed specifically to address complex wrist pathology was used for the internal fixation of 22 complex fractures of the distal radius in 22 patients in a prospective multicenter trial. The majority of fractures were group C2- and C3-type fractures according to the Comprehensive Classification of Fractures. No plate failures, loss of reduction, nonunions, or infections occurred. Within the average follow-up time of 14 months, the functional results (including an average motion of 76% and an average grip strength of 56% of the contralateral side) were comparable to those reported for similar fractures in previous investigations. Five patients had irritation of the tendons in the second dorsal compartment. This trial serves both as a verification of the safety and efficacy of this distal radius plate as well as a demonstration of its utility in the treatment of complex fractures of the distal radius.

Rotatory Instability of the Elbow. The Anatomy and Role of the Lateral Stabilizers

Posterolateral rotatory instability of the elbow has been attributed to disruption of the ulnar part of the lateral collateral ligament. Forty fresh cadavera were studied to define the ligamentous anatomy of the lateral aspect of the elbow specifically as it relates to rotatory instability. The dissections revealed a broad conjoined insertion of the lateral collateral and annular ligaments onto the proximal aspect of the ulna. This insertion was bilobed (type I) in twenty-two specimens and broad (type II) in eighteen specimens. Serial sectioning studies revealed primary and secondary stabilizers of the lateral aspect of the elbow. In addition to the lateral collateral ligament and the annular ligament, the extensor muscle origins provide stability through fascial bands and intermuscular septa. CLINICAL RELEVANCE: The findings of this study suggest that post-traumatic posterolateral rotatory instability of the elbow is the result of attenuation or disruption of both the ligamentous and the muscular origins from the lateral epicondyle of the humerus. Injury to these structures should be avoided during operative exposures for procedures such as débridement of the elbow for recalcitrant lateral epicondylitis, resection of the radial head, or capsular release for a stiff elbow. If immobilization is necessary postoperatively, the forearm should be held in pronation.

The lateral approach for operative release of post-traumatic contracture of the elbow.

A lateral approach was used to release a post-traumatic contracture of the elbow in seven patients, and the results were evaluated an average of thirty-eight months postoperatively. Extension improved from an average flexion contracture of 45 degrees preoperatively to one of 12 degrees postoperatively, and the average point of maximum flexion increased from 116 degrees preoperatively to 129 degrees postoperatively. The average arc of motion increased 46 degrees. All patients began using a continuous-passive-motion device immediately after the operation. There were no problems with wound-healing or formation of heterotopic bone.

Distal unicondylar fractures of the proximal phalanx.

The records of 38 consecutive patients (38 fractures) who underwent treatment for distal unicondylar fractures of the proximal phalanx were reviewed to evaluate fracture characteristics, mechanism of injury, treatment options, and functional outcomes. Four classes of fracture pattern were defined radiographically. Most fractures occurred during ball sports and involved an axial splitting of extended digits, with the condyle closet to the midline of the hand fracturing most commonly. We believed that the fracture occurred as a result of tension loading due to a distraction force from the collateral ligament. All fractures healed. Follow-up examination averaged 3 years. Five of seven nondisplaced fractures treated with splinting and four of ten displaced fractures treated with reduction and single Kirschner wire fixation displaced. Fractures treated with multiple Kirschner wire fixation had the best final joint motion. Class IV fractures with a small palmar coronal fragment had the poorest final motion. A short period of post-operative immobilization did not adversely affect final proximal interphalangeal joint motion. We recommend multiple Kirschner wire or miniscrew fixation of these fractures as the most predictable method of treatment. Final proximal interphalangeal joint motion is not uniformly excellent in patients with these fractures.

Acute elbow dislocation: evaluation and management.

&NA; Most elbow dislocations are stable after closed reduction. Treatment with an early range‐of‐motion program generally leads to favorable results. Care must be taken to rule out neurovascular involvement and associated osseous or ligamentous injury in the wrist. Late elbow instability and stiffness are rare after simple dislocations. Complex elbow dislocations with associated fractures may require surgical intervention to obtain joint stability; ligament and/or fracture repair is frequently necessary in this situation. Larger periarticular fractures adversely affect functional results. Potential late complications of elbow dislocation include posttraumatic stiffness, posterolateral joint instability, ectopic ossification, and occult distal radioulnar joint disruption.

Upper extremity function after wrist arthrodesis.

Several studies have examined the normal range of wrist motion used to accomplish activities of daily living. Little information is present, however, on what functional limitations might be experienced by patients actually undergoing formal wrist arthrodesis. This study undertook comprehensive functional evaluation of 23 patients who underwent wrist arthrodesis for post-traumatic conditions. Follow-up evaluation averaged 54 months and consisted of a clinical questionnaire, the Jebsen Hand Function Test, and a functional rating devised by Buck-Gramcko/Lohmann. Fifteen of the 23 patients returned to their original jobs, and all patients noted that although the vast majority of tasks could still be performed, these tasks were undertaken in a modified fashion. The most difficult daily tasks for patients with a wrist arthrodesis to perform involved perineal care and manipulating the hand in tight spaces. The Jebsen Hand Function Test demonstrated a 64% task completion rate with the fused wrist compared to a 78% task completion rate for the normal wrist. The Buck-Gramcko/Lohmann evaluations demonstrated an average score of 8.3 out of a possible 10. Patients who have undergone wrist arthrodesis can accomplish most activities of daily living and other functional requirements, although some adaptation to accomplish these tasks is required.

Arthrodesis of the Wrist for Post-Traumatic Disorders*

We retrospectively reviewed the records of eighty-nine consecutive patients (ninety wrists) who had had a total arthrodesis of the wrist for the treatment of a post-traumatic disorder at one center. Fifty-six patients (fifty-seven wrists) had the arthrodesis with plate fixation, and thirty-three patients (thirty-three wrists) had the arthrodesis with a variety of other techniques. The average age of the patients at the time of the arthrodesis was forty-two years, and the dominant wrist was treated in forty-two patients. Fifty-six (98 per cent) of the fifty-seven wrists that had been fixed with a plate had a successful union at an average of 10.3 weeks postoperatively. Twenty-seven (82 per cent) of the thirty-three wrists that had been treated with other methods had a successful union at an average of 12.2 weeks postoperatively. The difference in the rates of union between the wrists fixed with a plate and those treated with alternative techniques was significant (p = 0.009; Fisher exact test). A total of thirty-nine complications were associated with twenty-nine (51 per cent) of the fifty-seven arthrodeses with plate fixation. Sixteen (41 per cent) of the complications (thirteen wrists) resolved with non-operative treatment. Twenty-six (79 per cent) of the thirty-three arthrodeses with alternative methods of fixation were associated with a total of twenty-nine complications. Twenty-three (79 per cent) of those complications (twenty wrists) resolved with non-operative treatment. The difference between the rate of complications associated with the arthrodeses with plate fixation and that associated with the arthrodeses with alternative methods of fixation was significant (p = 0.03; Fisher exact test).

Wrist arthrodesis for traumatic conditions: A study of plate and local bone graft application

This study demonstrates the ability to obtain a predictable and complete wrist arthrodesis using local bone graft and a dorsal plate. The donor site morbidity often seen in using iliac crest graft is eliminated with this method. We examined the use of local distal radius bone grafting alone with dorsal plate fixation and its ability to provide a predictable fusion. Twenty-eight consecutive patients underwent wrist arthrodesis by a standard plate fixation technique. Average patient age was 34 years with an average period of symptom duration of 2.1 years. The cohort had undergone 17 previous wrist surgical procedures prior to wrist arthrodesis. The average followup examination period was 2 years. Grip strength, x-ray films, and range of motion were evaluated. All patients had a solid wrist arthrodesis at final follow-up examination. Grip strength, pronation/supination, and digital motion did not change significantly from the preoperative status. No patients complained of wrist pain or instability. Complications included extensor tendinitis at the distal aspect of the plate in four patients requiring plate removal, carpal tunnel syndrome requiring decompression, and distal radioulnar joint pain requiring intra-articular injection of corticosteroid.

Hemicondylar Hamate Replacement Arthroplasty for Proximal Interphalangeal Joint Fracture Dislocations: An Assessment of Graft Suitability

PURPOSE Proximal interphalangeal (PIP) joint fracture-dislocations are complex injuries, and successful surgical treatment can be challenging. The hamate appears to be an appropriate graft based on its general shape and dimensions. The purpose of this study was to evaluate the rationale and suitability of the hamate as an autograft for proximal interphalangeal joint fracture-dislocations and to determine the inherent stability of the donor site after graft harvesting. METHODS Fresh-frozen cadaveric hand specimens were used to evaluate the hamate as a suitable graft source for defects of the middle phalanx based on macroscopic, radiographic, and biomechanical properties. Radiographic measurements were made of the articular contours of the hamate and the base of middle phalanx of digits 2 through 5. Hemicondylar hamate replacement arthroplasty (HHRA) was performed in cadavers for defects created in the middle phalanges. Biomechanical stability testing of the hamate-metacarpal joint was then assessed in additional specimens before and after HHRA. Fluoroscopic examination with a 22.2-N load applied in a 45 degrees dorsal-proximal direction was used to assess stability of the carpometacarpal joints. A servohydraulic testing machine was then used to determine the amount of translation induced with a similarly directed force before and after harvesting of the hamate graft. RESULTS The cadaveric HHRA reconstructions restored joint stability with no tendency to subluxate. Radiographic measurement showed that the hamate has a central ridge and bicondylar facet with articular contours that are similar to the base of the middle phalanx. The removal of a central portion of the hamate did not induce dislocation or create obvious clinical instability of the carpometacarpal joint. CONCLUSIONS The HHRA technique is used for treatment of fracture-dislocations of the proximal interphalangeal joint. This study demonstrated the suitability of using the dorsal portion of the hamate as an osteochondral autograft for middle phalangeal base fractures; the technique creates minimal donor site morbidity.

Effect of proximal phalangeal fracture deformity on extensor tendon function

Extensor lag is a common sequella of proximal phalangeal fractures. Proximal phalangeal fractures frequently lead to extensor tendon dysfunction via adhesions and phalanx malunion with angulation and/or shortening. The primary purpose of this study was to quantify the influence of proximal phalangeal angulation and shortening on proximal interphalangeal (PIP) joint extension by examining the effect of isolated proximal phalangeal bone to extensor digitorum communis tendon discrepancy on PIP joint lag. The secondary goal was to determine the reserve of the extensor digitorum communis to overcome the PIP joint lag. A proximal phalangeal bone-extensor tendon discrepancy results in either a PIP lag or a potential lag that must be compensated for by another system, such as by overpull of the extrinsic extensor or by the pull of the intrinsics. Six cadaveric middle fingers were used, proximal phalangeal malunions were simulated, and the extensor lag was measured radiographically. A linear relationship between extensor tendon lengthening and the resulting PIP lag was observed. Similarly, a linear relationship between proximal phalangeal shortening and the lag was observed. For both, the average slope was 12 degrees of lag/mm of bone-tendon discrepancy. For average apex palmar angulations of 16 degrees, 27 degrees, and 46 degrees, PIP lags of 10 degrees, 24 degrees, and 66 degrees, respectively, resulted. The extensor tendon reserve was 2 to 6 mm. The sagittal bands became tight at the limits of the extensor tendon reserve. The results of this study quantify the importance of re-establishing the bone-tendon relationship for proximal phalangeal fractures.