Hyoung-Min Kim

Isolated fractures of the greater trochanter with occult intertrochanteric extension

IntroductionIsolated fractures of the greater trochanter (GT) are relatively rare. The diagnosis can be done on routine radiographs, but it is difficult to fully define the geographic extent of these injuries. This study examined the pattern and extent of an injury shown by magnetic resonance imaging (MRI) and radionuclide bone scan (RBS) in patients whose plain radiographs revealed fractures limited to the GT.Materials and methodsBetween July 2004 and October 2008, 25 patients who displayed an isolated GT fracture on plain radiograph examination were examined by both MRI and RBS due to a suspicion of an extension into the intertrochanteric (ITC) region. The patients were then divided into two groups. Group A patients had an isolated fracture of GT, and group B patients had an occult fracture of ITC.ResultsAll 25 cases were caused by a low-energy injury and plain radiographs showed non-displaced or minimally displaced isolated GT fractures. For 22 of the 25 patients, the result agreed with MRI and RBS. However, three patients had focal increased uptake at the GT region only according to RBS and an extension of signal intensity into the ITC region according to MRI. Group A and B comprised 5 and 20 patients, respectively. Of the group B patients, 8 had fractures with MRI evidence of complete extension across the ITC region and 12 had incomplete extension. Eleven of the 12 incomplete types showed an extension more than half way to the medial cortex. Fifteen group B patients underwent an internal fixation using a two-hole dynamic hip screw.ConclusionPatients with an isolated fracture of GT can have a broader fracture extending into the ITC region than that diagnosed by standard radiographs. We recommend that all patients presenting with an isolated GT fracture on the plain radiographs should undergo MRI examination.

Spontaneous anterior interosseous nerve syndrome: clinical analysis of eleven surgical cases

Abstract The aetiology of anterior interosseous nerve (AIN) syndrome and an optimal treatment strategy remain controversial. Eleven patients with spontaneous AIN syndrome, who were treated by surgical exploration, were reviewed at a mean of 32.5 months after the operation. Eight men and three women were included in the study. None of the patients had a history of trauma and there was no evidence of a neuropathy other than AIN syndrome. Six patients showed complete paralysis of the flexor pollicis longus (FPL) and the flexor digitorum profundus of the index finger (FDS1). Five patients had incomplete paralysis, with isolated lesions of the FPL in two and the FDP1 in three. Surgery was performed 7.8 months after the onset of paralysis. The most common structure of nerve compression was a fibrous band of the flexor digitorum sublimis muscle. However, no definitive compression site or anatomic abnormality could be found in four patients. Ten of the 11 patients had recovered muscle strength above grade 4 within 12 months of the operation. Good results were obtained in 10 patients and fair in only one at final assessment. Four patients (one man and three women) raised cosmetic concerns due to excessive scar formation on the upper forearm. Surgical exploration is recommended only in cases where AIN syndrome is apparent, no other neuronal lesions are apparent, and where there was no recovery after 6 months of conservative treatment. Careful preoperative examination is essential to avoid misdiagnosis and inappropriate operation, particularly in cases of incomplete AIN syndrome.

Simultaneous double dislocation of the interphalangeal joint in a finger

Isolated traumatic dislocation of the distal and proximal interphalangeal joints of the fingers is a common occurrence. However, simultaneous dislocation of both interphalangeal joints in a single finger appears to be a rare event. We report five cases of simultaneous dislocation of both interphalangeal joints in a single finger with a review of the literature.

Bilateral Carpometacarpal Joint Dislocations of the Thumb

A traumatic carpometacarpal joint dislocation of the thumb accounts for less than 1% of all hand injuries. Optimal treatment strategies for this injury are still a subject of debate. In this article, we report a case of bilateral thumb carpometacarpal joint dislocations: a unique combination of injuries. We believe our case is the second report of bilateral carpometacarpal joint dislocation regarding the thumb in English literature. It was successfully treated with closed reduction and percutaneous K-wires fixation on one side, and an open reduction and reconstruction of the ligament on the other side.

Giant cell tumor with secondary aneurysmal bone cyst: A unique presentation with an ossified extraosseous soft tissue mass

The authors describe a case of giant cell tumor (GCT) with secondary aneurysmal bone cyst (ABC) in a 44-year-old man with chronic, intermittent knee pain. A unique feature is the presentation of GCT with an ossified extraosseous soft tissue mass. Radiograph demonstrates a multiloculated lytic lesion in the distal meta-epiphyseal region of the femur with an adjacent extraosseous soft tissue mass. The soft tissue mass was partially ossified along its margin and internal septa. MRI demonstrates a multiloculated lesion in the distal femur with multiple fluid–fluid levels and cortical penetration of the lesion. Both the intraosseous lesion and extraosseous soft tissue mass have similar MR signal characteristics. At surgery, the intraosseous component was found to be contiguous with the extraosseous soft tissue mass through a cortical perforation. To the best of our knowledge, this is the first case report of GCT with aneurysmal bone cyst initially presenting with an extraosseous soft tissue mass.

Coexisting avascular necrosis of the scaphoid and lunate

Abstract Reports of coexisting avascular necrosis of more than one carpal bone are rare. We report coexisting avascular necrosis of the scaphoid and lunate in a 56-year-old woman with no history of using steroids or injury. We treated her with a radioscapholunate fusion with two angled 2.4 mm distal radius plates to stabilise the locking plate. At her 12-month follow up there was no evidence of non-union.

Re: Angioleiomyoma in the digit causing bony destruction

A 42 year-old, right-handed man presented with a painful lump on his left thumb that had been growing slowly over several months. The thumb had not been injured. Examination revealed a 1.5 1 cm, firm and tender mass on the dorsal aspect lying just proximal to the interphalangeal joint. Thumb movement and sensation were normal. Plain radiographs revealed an osteolytic lesion of the proximal phalanx with cortical disruption (Fig 1a). A technetium scintigraph demonstrated a marked increase in uptake over the proximal phalanx. The T1and T2-weighted and enhanced MR images confirmed a 1.3 0.9 1.2 cm solid mass. Cortical destruction and extension of the lump into the medullary canal were noted. The centre of the mass was necrotic with myxoid changes (Fig 1b). Exploration under regional anaesthesia revealed a tumour under the extensor pollicis longus invading the medullary canal and breaching the cortical bone. However, the lump was not connected to the digital arteries. The cartilage over the head of the proximal phalanx was preserved. The mass was excised and the medullary canal was curetted. Histopathological examination demonstrated a non-encapsulated nodular tumour consisting of smooth muscle bundles that were closely compacted and intersecting one another surrounded by thick fibrous tissue. The smooth muscle fascicles had uniform spindle cells with eosinophilic cytoplasm, and cylindrical nuclei with blunted ends. Blood vessels that formed slit-like vascular channels were surrounded by proliferating cells. Immunohistochemical studies demonstrated that the spindle cells contained smooth muscle actin and desmin. The results of CD-34 and S-100 protein staining were negative. These features confirmed the diagnosis of angioleiomyoma. Autogenous cancellous bone in the iliac crest was grafted 2 weeks later. Thirteen months after surgery there was no recurrence. The thumb regained a normal range of motion. Angioleiomyoma is a benign solitary smooth muscle cell tumour that originates from the tunica media layer of the arterial or venous walls. It is usually found in the lower extremity with 510% of cases occurring in the upper limb. Digital angioleiomyoma is rare without distinctive clinical features. Such a lump cannot be distinguished from other solid lesions such as a lipoma, foreign-body granuloma, giant-cell tumour of the tendon sheath, inclusion cyst and rarer lesions such as a hemangioma, angiolipoleiomyoma, neurofibroma, neurolemmoma and glomus tumour. Diagnosis is made only after excision and histopathological examination of the tumour. Bone involvement by an angioleiomyoma is rare. Only four cases have been reported with bone changes due to compression. Glowacki and Weiss (1995) reported an angioleiomyoma of the finger extending in a horseshoe-shaped fashion, between the flexor tendons and proximal phalanx of the hand, causing bone erosion. Yates (2001) reported two cases of angioleiomyoma that eroded the adjacent bone of the foot.

Extension limitation and deviation of fingers by the scarred junctura tendinum: a case report.

The juncturae tendinum (inter-extensor connections) are structures connecting each of the extensor digitorum communis (EDC) tendons. Nine months before the presentation to us, this 21-year-old man had painful swelling on the dorsum of the right hand after punching. At present, the patient showed an ulnar deviation of the long finger and a limited extension of the ring finger. The scarred junctura tendinum between long and ring fingers inhibited proximal sliding of the EDC tendon of ring finger, and affect the functions of adjacent metacarpophalangeal joint. The scarred junctura tendinum was resected, while the sagittal band was preserved to prevent subluxation of the EDC tendon of long finger. One year after operation, the range of motion of fingers was full.

Subtrochanteric fracture after free vascularised fibular grafting for osteonecrosis of the femoral head.

The aim of this study was to determine the incidence and factors associated with subtrochanteric fracture after free vascularised fibular grafting for osteonecrosis of the femoral head, and to analyse clinical and radiological outcomes of open reduction and internal fixation. From April 1991 to May 2004, eight such fractures were managed by Rowe plate fixation. Factors examined included age, gender, side of operation, cause and preoperative and postoperative stage of osteonecrosis, and preoperative and postoperative functional assessment. The osteonecrosis was caused by alcohol consumption in six, steroid use in one and was idiopathic in one case. The overall incidence of fracture was 4.1% (13.9% in bilateral operations) and all occurred in men of mean age 36.3 years, were induced by low-energy injury and were attributed to defects created in the lateral femoral cortex for graft placement. Seven of the eight fractures (87.5%) developed within 12 weeks and all fractures healed at a mean of 16.6 weeks after internal fixation. No major complications occurred and no significant differences were found in clinical or radiological results between the fracture and non-fracture groups. Our findings indicate that strict education and mandatory protection from full weight bearing are required for 12 weeks after free vascularised fibular grafting for osteonecrosis of the femoral head.

An intraosseous epidermal cyst developing in a metacarpal bone after K-wire fixation: a case report

Intraosseous epidermal cysts (IECs) are rare benign lesions caused by the proliferation of epidermal cells within the bone. The pathogenesis of IEC remains unclear; however, trauma-triggered infiltration of the bone by epidermal elements has been suggested. Here, we present a case of an IEC in the metacarpal bone of the little finger associated with K-wire fixation for treatment of a fifth metacarpal fracture.