James L. Hughes

Comminuted fractures of the proximal radius and ulna.

Forty-three comminuted fractures of the proximal radius and ulna in 34 patients were treated with operative stabilization using AO/ASIF techniques. The patients were divided into three groups, according to the type of injury: Group I, isolated comminuted fractures of the olecranon (18 patients); Group II, isolated fractures of the radial head (eight patients); Group III, combined olecranon and radial head fractures (eight patients). All fractures were followed until union. The average follow-up period was 18 months (range, 12-48 months). At the time of this review, the average limits of elbow motion were 20 degrees extension, 118 degrees flexion, 65 degrees pronation, and 62 degrees supination. Two patients were unable to return for follow-up examination. Using the functional classification of Broberg and Morrey, results were rated as excellent in nine cases, good in 15, fair in five, and poor in three. The complication rate in this series was 19%: Two patients developed nonunion, and one patient lost reduction during rehabilitation. All of these patients required reoperation, with eventual satisfactory outcome. Three patients developed heterotopic ossification, two of which were minor and one of which produced ankylosis of the elbow joint. Each of these patients had delayed (more than 72 hours postinjury) stabilization. A functional elbow was achieved in 29 of the 32 patients who returned for follow-up examination. Operative stabilization of comminuted fractures of the proximal radius and ulna provides a stable painless joint with a functional, but not full, range of motion.

Tire explosion injuries.

Twenty-five patients hospitalized with injuries sustained from tire explosions from 1980 to 1987 were reviewed. Injuries occurred directly from the tire rim or parts of its assembly, from the patient being thrown against adjacent unyielding structures, or a combination of these. Lethal or life-threatening injuries do occur, so these patients initially must be triaged as polytrauma patients. Resuscitation and expeditious attention to life-threatening injuries must be provided when necessary. Serious head, facial, eye, and upper extremity injuries occurred frequently. Pelvic and long-bone fractures, particularly those of the femur, are stabilized primarily as part of the overall treatment of the polytraumatized patient. Open fractures and fractures with arterial injuries and/or compartment syndromes are primarily decompressed, debrided, and appropriately stabilized. After life-threatening and limb-threatening injuries are attended, eye injuries that threaten sight should be addressed. While hand, wrist, and other upper extremity injuries that do not fall in the above categories may not require immediate or primary treatment, they are often critical in determining the patients final outcome. This is particularly true since most patients are manual workers, often mechanics. Therefore, hand, wrist, and upper extremity injuries should be treated as early as possible and in parallel with other injuries to achieve optimal results and minimize impairment, disability, and time and economic loss from work. Strong emphasis should be placed on education and safety training in preventing this severe form of civilian trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

The mechanical integrity of healed diaphyseal bone defects grafted with calcium hydroxyapatite/calciu triphosphate ceramic in a new animal model

The need for an animal model to test bone graft materials simulating a weight bearing clinical situation is identified. The concept, design and operative detail of a new model is described. This model involved the creation of a mid-diaphyseal wedge defect in the femur of the adult beagle which separated both cortices, plating with a six-hole dynamic compression plate, and allowed immediate full weight bearing. At six months plates were removed and immediate weight bearing was allowed for an additional six months to sacrifice. The initial animal project utilizing this model to evaluate a hydroxyapatite based synthetic graft material was performed using 12 dogs. In addition to the operative procedure, the retrieval testing in torsion of 12 healed grafted bones and their 12 contralateral unoperated controls is described and evaluated. Results showed no statistically significant difference between the torsional strength of test and control femurs (p less than or equal to 0.05). In addition, the future development of the model is discussed.

Intraarticular Metacarpal Head Fractures

Metacarpal head fractures usually result from direct impact. They are frequently comminuted and, in these instances, are difficult, if not impossible, to repair. The problem is frequently compounded by the Degrees of dissection required to expose the articular surface adequately. One runs the risk of devascularizing important fragments that may have little or no soft tissue attachment. If there is a single large fragment or, if comminuted, one or two major fragments, lag screw fixation may be possible (Figs.19-1 A Figs.19-1 B Figs.19-1 C). The goal of treatment is to restore the congruity of the articular surface and to stabilize it insofar as possible so that cautious motion can be started immediately. In some instances, tension band wiring alone or combined with interosseous wiring may be used (Figs. 19-2 A-H). Early motion is a critical aspect of management of these fractures, which is more likely, in order, after lag screw fixation, tension band and interosseous wiring, and Kirschner wire fixation.

The AO / ASIF Principles:Fracture (Cast) Disease

Restoration of anatomic relations correlates highly with functional outcome in the hand. The priorities in treatment are a stable, well-maintained reduction and early motion. Prolonged immobilization, especially in a nonfunctional cast, can lead to a vicious cycle of pain, swelling, and unresolved edema. Edema fluid is a proteinaceous exudate that will congeal into scar tissue around joints and tendons and cause joint stiffness, contracture, and tendon adhesions. Muscle atrophy, brawny skin /induration, and osteoporosis follow. Reflex sympathetic dystrophy may sometimes occur and further complicate the picture. This constellation of symptoms and physical changes has been called “fracture disease.” Like proud flesh and suppuration in soft tissue healing, it is not a necessary part of fracture repair and can be avoided. Prevention is the best treatment. All fracture treatment, whatever the method, must be geared to achieve stability and function to prevent these complications.

Oblique and Spiral Metacarpal Shaft Fractures

Spiral and oblique metacarpal shaft fractures are caused by torquing forces. These fractures tend to shorten and rotate but, on occasion, may angulate (Figs. 17-1 A, B). The border metacarpals are less stable and become deformed more than the internal metacarpals when fractured individually because the internal metacarpals are protected on either side by an intact metacarpal pillar whose deep transverse metacarpal ligaments tether the distal fragment. Five Degrees of malrotation in a metacarpal fracture can cause 1.5 cm of digital overlap. Malrotation causing digital overlap must be corrected (Fig. 17-1 C).

Limited Intercarpal Arthrodesis

Limited intercarpal arthrodesis may be used to immobilize specific intercarpal joints within the wrist without loss of total wrist motion. Triscaphe arthrodesis is used to retain substantial wrist motion while preventing carpal collapse in instances of scapholunate dissociation and Kienbocks disease (Figs. 44-1 A Figs. 44-1 B Figs. 44-1 C Figs. 44-1 D Figs.44-1 E-F). Capitate hamate arthrodesis may be performed to prevent carpal collapse and to relieve symptoms and allow revascularization in early Kienbocks disease before breakdown of the lunate.Capitate hamate arthrodesis may prevent intercarpal collapse by stabilizing the capitate after excision of a lunate from State III Kienbocks disease, but because of the loss of the scapholunate ligaments, this procedure may not control the position of the scaphoid after removal of the lunate, as will a triscaphe fusion. (Figs. 44-2 A-C). Other limited intercarpal arthrodeses may be performed for various intercarpal instability patterns and related injuries.

Thumb Interphalangeal Joint Arthrodesis

Arthrodesis is an excellent and effective way to reconstruct the deformed, destroyed, or unstable interphalangeal joint of the thumb. Position can be from 0 to 30 degrees of flexion and is adjusted to suit the needs of the individual patient. Methods of stable fixation of thumb interphalangeal joint arthrodesis include screw (Figs. 51-1 A Figs. 51-1 B Figs. 51-1 C Figs. 51-1 D) and tension band wire techniques. Tension band wire technique was demonstrated in Figures 50-2 A-K. When the screw is inserted retrograde, it is important to countersink the distal portion of the distal phalanx in order to better accommodate the screw head.

Thumb Trapeziometacarpal Joint Arthrodesis

Arthrodesis of the trapeziometacarpal joint of the thumb may be indicated for posttraumatic arthritis, osteoarthritis, rheumatoid arthritis, or chronic subluxation or dislocation. The advantages of arthrodesis of this joint over arthroplasty are stability, strength, power, and endurance. There should be satisfactory function of the two distal joints of the thumb, since their motion must compensate for the loss at the proximal fused joint. Marked trapezioscaphoid arthritis is a contraindication to the procedure, although mild arthritis is not.

Multiple Metacarpal Fractures

Whenever more than one metacarpal is fractured and displaced, each fracture compounds the instability, deformity, and muscular imbalance created by the other. In such injuries, it is particularly important to restore anatomy and stability to avoid permanent deformity, dysfunction, and stiffness (Figs. 20-1 A Figs. 20-1 A Figs. 20-1 C Figs. 20-1 D, 20-2 A-E, 20-3 A-G, 20-4 A-H). If the fractures are not adequately reduced, as the metacarpals shorten, the metacarpophalan-geal joints creep into extension and gradually stiffen there, with loss of the longitudinal arch. The surrounding soft tissue becomes indurated and edematous, and fracture disease, as described in Chapter 3, can occur. Whenever there is marked dorsal angulation of a metacarpal fracture, the adjacent metacarpal bases should be inspected for fracture or dislocation (Figs. 20-3 A-G).