James B. Bennett

Simple dislocation of the elbow in the adult. Results after closed treatment.

The long-term results after treatment of simple dislocation of the elbow in fifty-two adults were evaluated with regard to limitation of motion, pain, instability, and residual neurovascular deficit. All patients were treated with traditional closed reduction, but the duration of immobilization before commencement of active motion varied. Goniometric, photographic, and radiographic data were compiled for these patients, who had an average follow-up of 34.4 months. Despite the generally favorable prognosis for this injury, 60 per cent of the patients reported some symptoms on follow-up. A flexion contracture of more than 30 degrees was documented in 15 per cent of the patients; residual pain, in 45 per cent; and pain on valgus stress, in 35 per cent. Prolonged immobilization after injury was strongly associated with an unsatisfactory result. The longer the immobilization had been, the larger the flexion contracture (p less than 0.001) and the more severe the symptoms of pain were. The results indicate that early active motion is the key factor in rehabilitation of the elbow after a dislocation.

Arthroscopic subacromial decompression An anatomical study

Anterior acromioplasty as described by Neer has been an effective procedure for shoulder impingement syn drome. Recent presentations by Ellman suggest that an effective acromioplasty may be performed arthros copically. These clinical reports have not been sup ported by any laboratory experience. The purpose of our study was to examine the feasibility and attempt to quantitate the results of arthroscopic subacromial de compressions. Six acromioplasties were performed according to the recommended technique of Dr. Neer to create a stand ard for comparison. Fourteen fresh postmortem speci mens were studied. In seven shoulders a standard acromioplasty was performed with an osteotome. In seven shoulders an acromioplasty was performed using standard arthroscopic approaches and motorized in struments. In five shoulders an isolated division of the coracoacromial ligament was performed arthroscopi cally. The coracoacromial ligament was completely di vided in all five cases. In the osteotome group adequate bone was resected in 75% (21/28) measured locations. In the arthroscopic group adequate bone was removed at 86% (24/28) location. This difference is not statisti cally significant. In the cadaver, anterior acromioplasty was performed effectively and predictably with arthroscopic instru ments. This compared favorably to a conventional os teotome acromioplasty. It was concluded that coraco acromial ligament division can be accomplished.

Carpal arch alteration after carpal tunnel release

A retrospective clinical study quantitated postoperative widening of the transverse carpal arch after carpal tunnel release in a group of 50 patients. The relationship of this widening with postoperative pain, forearm circumference, grip strength, and wrist range of motion was evaluated. Mean widening of the transverse carpal arch after carpal tunnel release is 10.4% or 2.7 mm. A direct relationship exists between widening of the transverse carpal arch and loss of grip strength. Residual pain, forearm circumference, and wrist range of motion are not related to widening of the transverse carpal arch.

Intraarticular fractures of the distal humerus in the adult

Intraarticular fractures of the distal humerus are notoriously difficult to treat. Three basic treatment methods are available: closed reduction, traction, and open treatment. In the past, functional results with all these methods generally have been poor because of disabling limitations of elbow motion. Thirteen adult patients were treated by open reduction and application of medial and lateral buttress plates providing rigid internal fixation and early motion. The patients were evaluated for range of motion, infection, nerve injury, avascular necrosis, myositis ossificans, varus/valgus deformity, pain, instability, weakness, and degenerative changes. Ten of the 13 patients were available for follow-up study for an average of two years. Nine of the ten achieved good or excellent results. Based on these observations, the treatment of choice is internal fixation with dual plates combined with early active postoperative motion.

Complications of distal radial fractures: Pins and plaster treatment

Recent advances in the treatment of comminuted distal radial fractures has led to the use of pins and plaster, a concept described by many authors. This paper examines whether the use of pins and plaster maintains reduction of distal comminuted radial fractures, and, if so, if it is accomplished with a minimum of complications. With follow-up ranging from 1 month to 1 year following pin removal, 80 consecutive comminuted distal radial fractures treated with pins and plaster were analyzed for change in fracture reduction, associated injuries, and complications incurred during and as a result of the treatment mode. Thirty-three percent of our patients had some complications due to their pins and 16% required reoperation for carpal tunnel syndrome or replacement of loose pins, sequestrectomy, or extended treatment in long arm casts.

Surgical management of chronic medial elbow instability.

Chronic medial elbow instability in the active adult working population is a rarely diagnosed entity. Although it is recognized in the professional athlete as a cause of disability, reports in the general population do not exist. Fourteen adult patients with symptomatic chronic medial instability were evaluated from 1982 to 1986. Surgical reconstruction of the medial collateral ligaments was performed with follow-up evaluation averaging two years. Symptomatic complaints, physical examination, and roentgenographic evaluation were recorded preoperatively. Range of motion, postoperative stability, ulnar nerve symptomatology, and activity level were recorded postoperatively. All but one patient reported improved stability of the elbow.

Compression syndrome of the recurrent motor branch of the median nerve

Carpal tunnel compression and its surgical release has been well described. Motor branch anomalies of the median nerve have also been documented in the literature. Independent recurrent motor branch compression of the median nerve appears to exist in the presence of carpal tunnel symptomatology or as an independent entity. Eight presentations of concomitant or independent compression of the recurrent motor branch of the median nerve have been reviewed. These cases can be subdivided into cases presenting with or without carpal tunnel symptomatology, as well as into two types of independent compression patterns: the first being a direct fascial penetration and entrapment and the second being an acute angulation of the recurrent branch with apparent impingement by the transverse carpal retinaculum. Attention should be directed to the inspection and decompression of the motor branch of the median nerve in those cases that present thenar muscle pathology either clinically or electrodiagnostically.

Failure of trapeziometacarpal arthrodesis with use of the Herbert screw and limited immobilization

Eighteen patients with trapeziometacarpal joint arthritis had arthrodesis with use of the 1.9 mm Herbert screw for internal fixation. Thumb spica cast immobilization was maintained for an average of 8 weeks, followed by thumb spica orthoplast splintage on a part time basis. Fourteen patients had radiographic follow-up an average of 12 months after operation. Seven had union and seven had a nonunion. There were three fixation-related complications and two nonfixation-related complications. Eleven patients had clinical follow-up an average of 12 months after operation. Four patients had no pain, five had mild pain, and two had moderate pain after operation. All had severe pain before operation. All were satisfied with the procedure. Although subgroups of patients had a higher rate of union with bone grafts or with immobilization over 8 weeks, the theory that arthrodesis with 1.9 mm Herbert screws does not require external splintage and allows early mobilization is not supported by this series.

Power staple fixation in trapeziometacarpal arthrodesis

Twenty-seven trapeziometacarpal arthrodeses were performed in 26 patients for basilar thumb joint arthritis utilizing power staple fixation. Short arm thumb spica cast immobilization was maintained for an average of 8 weeks, followed by part-time splintage for 6-12 weeks. Twenty patients were available for evaluation an average of 19 months after the operation. All of the patients were satisfied with the procedure. Thirteen had complete relief of pain, four had mild pain, and three had moderate pain after surgery. The two nonunions that occurred were in patients that refused postoperative casting and both had complete pain relief. There were no fixation-related complications in the remaining 18 patients that were casted postoperatively, and all developed a solid fusion. Power staple fixation in trapeziometacarpal arthrodesis has a 90% union rate with no long-term fixation related complications.

RIGID INTERNAL FIXATION FOR SHOULDER ARTHRODESIS

Fifteen patients underwent a shoulder arthrodesis utilizing standard dynamic compression plate fixation, but with limited postoperative immobilization with only an abduction pillow. In each case, the position of the extremity relative to the scapula and trunk was recorded immediately postoperatively, at regular intervals until fusion, and at follow-up evaluations. Thirteen of 15 shoulders fused without change of intraoperative position after an average postoperative period of 4 months. One patient lost position in the early postoperative period secondary to inadequate fixation, but subsequently fused. Another who demonstrated a persistent non-union at 2 1/2 years was subsequently explored and underwent a bone graft. Four patients complained of residual symptomatic hardware, with two requiring surgical removal of the plate and screws. All but one patient were satisfied with the clinical result at follow up. Only two patients were within 5 degrees of the preoperatively determined position of 30 degrees abduction, 30 degrees forward flexion, and 30 degrees internal rotation. However, almost all were able to function satisfactorily. The authors concluded that shoulder arthrodesis utilizing rigid internal fixation without postoperative cast or brace immobilization maximizes patient comfort without compromising the success of arthrodesis. However, control of arm position remains inexact and additional modifications are needed to ensure fusion position and to minimize disability.