John D. Lubahn

Nonoperative Treatment of Distal Biceps Tendon Ruptures Compared with a Historical Control Group

BACKGROUND Few data are available regarding the results of nonoperative treatment of distal biceps ruptures. The present study was designed to assess the outcomes associated with unrepaired distal biceps tendon ruptures. METHODS Eighteen patients with twenty unrepaired distal biceps tendon ruptures were assessed retrospectively. The median duration of follow-up was thirty-eight months. Sixteen of the eighteen patients were male, and the median age at the time of the injury was fifty years (range, thirty-five to seventy-four years). Supination strength and elbow flexion strength were measured bilaterally, and patient outcomes were assessed with use of the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire. Data were compared with historical controls compiled from six published series of operatively treated patients. RESULTS The median supination and elbow flexion strengths for the injured arm were 63% (mean, 74%; range, 33% to 162%) and 93% (mean, 88%; range, 58% to 110%) of those for the contralateral arm, compared with values of 92% (mean, 101%; range, 42% to 297%) and 95% (mean, 97%; range, 53% to 191%) for the historical controls that had been treated surgically. The difference between the mean values was significant for supination strength (p = 0.002) but not for flexion strength (p = 0.164). Patients had satisfactory outcomes overall, with median scores on the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire of 85, 95, and 9, respectively. CONCLUSIONS Nonoperative treatment of distal biceps tendon ruptures can yield acceptable outcomes with modestly reduced strength, especially supination.

Role of antibiotics in open fractures of the finger.

The role of antibiotics was investigated prospectively in 91 open fractures of the finger. Antibiotics were administered to alternate patients with open phalangeal fractures. Only finger fractures distal to the metacarpophalangeal joint were included. Both groups were treated with aggressive surgical irrigation and debridement. In four patients in each group clinical signs of infection eventually developed; osteomyelitis did not develop in any patients, and no secondary surgical procedures were required in either group. This data indicates that vigorous irrigation and debridement is adequate primary treatment for open phalangeal fractures in fingers with intact digital arteries.

Complications of Open Trigger Finger Release

PURPOSE Open release of A1 pulleys for trigger finger has been thought of as a relatively benign procedure with a low complication rate. Few studies have examined the rate of complications in trigger finger release. The objective of this study was to retrospectively review the complications documented for a cohort of patients who received open trigger finger releases. METHODS We conducted a retrospective chart review of 43 patients who had had 78 open trigger finger releases by a single surgeon. Any postoperative complications that were documented were recorded. Complications were then divided into major and minor. Major complications required further surgery or resulted in significant limitations of activities of daily living; minor complications hindered recovery, responded to treatment (if applicable), and either resolved or had little impact on function. RESULTS Two major complications were noted: a synovial fistula that required excision, and proximal interphalangeal joint arthrofibrosis that required cast application for pain relief. The major complication rate was 3% per trigger release (2/78). Twenty-seven minor complications in 22 digits were documented for these cases, including decreased range of motion, scar tenderness, pain, and wound erythema. The minor complication rate was 28% (22/78). The overall, combined complication rate for these primary interventions was 31% (24/78). CONCLUSIONS Open trigger finger release is thought to be a low-risk procedure by most practitioners. In this study, we found that major complications do occur infrequently; however, the rate of minor complications was surprisingly high and related mostly to wound complications or loss of finger range of motion. The surgeon performing open trigger finger releases should inform the patient of the likelihood of having these minor complications.

Mallet finger fractures: A comparison of open and closed technique

A mallet finger associated with a fracture of the distal phalanx may be treated by closed or open technique. Traditionally, it has been taught that fractures involving more than one third of the articular surface or where the joint is subluxed require open tratment with anatomic restoration of the articular surface.’ Numerous surgical techniques have been proposed and include the use of a tension band wire,2 intramedullary wire fixation,’ external fixation with Kirschner wires as a tension band device,” and fixation with a small lag screw.5 The relative difficulty of all these procedures has led Wehbe and SchneideP to conclude that most mallet finger fractures

Fractures of the distal interphalangeal joint.

Fractures at the distal interphalangeal joint present a therapeutic challenge to the hand surgeon because of the relatively small bones and joint surfaces involved and the limited internal fixation devices available. Knowing which patients and which fractures are best treated surgically is key to a successful result. The normal anatomy and biomechanics of the joint are outlined and overviewed and the anatomy, etiology, therapy, and classification are discussed. Comminuted fractures of the articular surface of the distal phalanx are presented as are epiphyseal fractures of the distal phalanx. Avulsion of the profundus tendon (jersey finger) is discussed, emphasizing Leddy and Packers Types I, II, and III injuries and the recommended treatment. Condylar fractures of the articular surface of the middle phalanx at the distal interphalangeal joint are the subject of the next section, with Londons classification scheme and recommended treatment. Finally, complex open injuries and replantation through the distal interphalangeal joint are presented with guidelines for salvage and treatment.

Fasciectomy and Dupuytren's disease: A comparison between the open-palm technique and wound closure

An analysis of 153 patients treated surgically for Dupuytrens disease is presented. One hundred fifteen patients were treated with the closed-palm technique, while 38 patients were treated with the open-palm technique. The groups were comparable in terms of preoperative metacarpophalangeal and proximal interphalangeal joint involvement, as well as the total number of rays involved. The patients were analyzed in terms of average pre- and post-operative total active motion (TAM) in the digital joints. The patients in the closed-palm group had a 10% improvement in TAM surgery, while those in the open-palm group had a 17% improvement (p less than 0.05). The complication rate in the closed-palm group was 19% and in the open-palm group, 8%. There were no hematomas in the open-palm group and no infections in either group. In a later follow-up of 103 patients who could be contacted, 33 of the 78 closed-palm group showed residual contracture (42%), while five of the 25 open-palm group were similarly affected (20%).

Palmar lipomas associated with compression of the median nerve.

The records of five patients who had had a palmar mass associated with altered sensibility in the distribution of the median nerve were reviewed retrospectively. Three-dimensional imaging (computerized tomography or magnetic resonance imaging) proved useful for establishment of the diagnosis of a lipoma and planning of the operative procedure. Treatment included release of the transverse carpal ligament, excision of the tumor, and exploration of the carpal canal and the median nerve and its distal digital branches. At an average of twenty-four months postoperatively, all patients had a complete return of sensibility and resolution of the discomfort.

The Hoffmann-Tinel sign

The aim of this article is to show that the well-known Tinel sign is realiy a Hoffmann-Tinel sign. The translation of the two papers of Hoffmann, published in the same year that Tinel wrote his article (1915), is completed by a short biography of Paul Hoffmann.

The digital tourniquet: How safe is it?

To measure the pressure generated beneath a digital tourniquet, this study was based on the mathematical relationship between pressure and resistance in latex rubber. The digital tourniquets were either a 1/4-inch Penrose drain or a rolled glove finger. Pressures generated beneath the rolled glove finger were noted to range between 200 and 1200 mm Hg. Pressure beneath the Penrose drain ranged between 100 and 650 mm Hg in one study group and between 120 and 500 mm Hg in a second study group consisting of fingertip injuries. A method was developed based on the same mathematical relationship to control pressure. Marks spaced 26 mm apart on a Penrose drain are wrapped around a finger until the marks touch and the Penrose drain is clamped. With this technique, the pressure beneath the Penrose drain will remain between 250 and 375 mm Hg. Less strain will be required for smaller fingers and more strain will be required for larger fingers; however, the pressure will remain within a predictable range.

Orthopaedics, ethics, and industry. Appropriateness of gifts, grants, and awards.

At the Academic Orthopaedic Society meeting in San Francisco on November 8 and 9, 1996, the membership addressed the issue of ethics and industry in an academic setting. Using a Delphi panel technique, they arrived at a definition of conflict of interest, and 41 separate points of acceptable and unacceptable behavior related to gifts, research awards, and funding of various activities. The Academic Orthopaedic Society Delphi Committee also mailed 191 questionnaires (157 department chairpersons and 34 program directors) to 157 training programs. The respective department chairpersons and program directors were asked to copy and distribute the questionnaires to staff (faculty) and house officers (residents and fellows) to complete anonymously and return them for collation. Ninety-one programs (58%) responded. Three hundred and fifty-two questionnaires were returned (237 from staff, 115 from house officers), each of which expressed agreement or lack of agreement with the Delphi panel report using a Likert scale technique. With only modest (and usually predictable) disagreement on certain items, the final statements by the Delphi panel were supported strongly by the survey results. The Academic Orthopaedic Society believes that the major points arrived at by the panelists should serve as the basis for ethical guidelines in the relation between academic orthopaedic institutions and industry.