Jorge G. Boretto

A Comparison of Intercostal and Partial Ulnar Nerve Transfers in Restoring Elbow Flexion Following Upper Brachial Plexus Injury (C5-C6±C7)

PURPOSE Restoring active elbow flexion is essential in the surgical management of C5-C6 +/- C7 brachial plexus palsies. This study compares the clinical results of 2 techniques to restore elbow flexion: the partial ulnar nerve transfer and the intercostal nerve transfer. METHODS Partial ulnar nerve transfer was performed in 23 patients, and intercostal nerve transfer was performed in 17 patients. For both techniques, the transfer to the musculocutaneous nerve was made at the same anatomical point. Age and preoperative delay were comparable between groups of patients. RESULTS Biceps reinnervation time was significantly earlier (p = .001) in the ulnar nerve technique (mean, 5.1 mo) than the intercostal nerve technique (mean 9.9 mo). Ten of 17 patients recovered useful elbow flexion force (British Medical Research Council grade >M3) in the intercostal nerve transfer group, compared with 20 of 23 patients in the ulnar nerve transfer group. No patient who had surgery more than 6 months after the injury recovered useful elbow flexion force in the intercostal nerve transfer. Elbow flexion strength was better in patients less than 30 years old in the intercostal nerve group. No complications were observed in either group. CONCLUSIONS This study shows that transferring fascicles of the ulnar nerve yields better results than intercostals nerve transfer for restoring elbow flexion. Moreover, preoperative delay and age are important preoperative prognostic factors for the intercostal nerves transfers. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Carpal tunnel syndrome - Part I (anatomy, physiology, etiology and diagnosis),

Carpal tunnel syndrome (CTS) is defined by compression of the median nerve in the wrist. It is the commonest of the compressive syndromes and its most frequent cause is idiopathic. Even though spontaneous regression is possible, the general rule is that the symptoms will worsen. The diagnosis is primarily clinical, from the symptoms and provocative tests. Electroneuromyographic examination may be recommended before the operation or in cases of occupational illnesses.

Proximal radio-ulnar synostosis and nonunion after olecranon fracture tension-band wiring: A case report

Fractures of the olecranon are the most common type of elbow fracture. Displaced fractures usually require operative treatment with open reduction and internal fixation to allow early motion in order to avoid significant stiffness of the elbow joint. Two parallel Kirschner wires inserted across the fracture into the medullary canal of the proximal ulna combined with a tension band wiring is a recognized and frequently performed method of fixation for noncomminuted fractures. Although isolated closed fractures of the olecranon in adults have a favorable long-term outcome, a few complications with this technique have been reported. The most common complication is migration of the K wires proximally leading to pain and local skin complications, with a high incidence (80%) of reoperation for the removal of symptomatic hardware. Therefore, this method has been modified so that the distal end of the Kirschner wires are inserted through the anterior cortex of the proximal ulna to prevent proximal wire migration postoperatively and to increase the stability of the tension band unit. The authors present a case of a patient with an isolated fracture of the olecranon that developed a proximal radioulnar synostosis and an olecranon nonunion associated with the use of the transcortical tension-band wiring technique. The possible mechanism for the synostosis formation, different from others described previously in accordance with the literature reviewed, will also be discussed herein below.

Non-surgical functional treatment for displaced olecranon fractures in the elderly

We retrospectively evaluated the clinical and radiological outcomes of a consecutive cohort of patients aged > 70 years with a displaced fracture of the olecranon, which was treated non-operatively with early mobilisation. We identified 28 such patients (27 women) with a mean age of 82 years (71 to 91). The elbow was initially immobilised in an above elbow cast in 90° of flexion of the elbow for a mean of five days. The cast was then replaced by a sling. Active mobilisation was encouraged as tolerated. No formal rehabilitation was undertaken. At a mean follow-up of 16 months (12 to 26), the mean ranges of flexion and extension were 140° and 15° respectively. On a visual analogue scale of 1 (no pain) to 10, the mean pain score was 1 (0 to 8). Of the original 28 patients 22 developed nonunion, but no patients required surgical treatment. We conclude that non-operative functional treatment of displaced olecranon fractures in the elderly gives good results and a high rate of satisfaction.

Carpal tunnel syndrome - Part II (treatment),

The treatments for non-deficit forms of carpal tunnel syndrome (CTS) are corticoid infiltration and/or a nighttime immobilization brace. Surgical treatment, which includes sectioning the retinaculum of the flexors (retinaculotomy), is indicated in cases of resistance to conservative treatment in deficit forms or, more frequently, in acute forms. In minimally invasive techniques (endoscopy and mini-open), and even though the learning curve is longer, it seems that functional recovery occurs earlier than in the classical surgery, but with identical long-term results. The choice depends on the surgeon, patient, severity, etiology and availability of material. The results are satisfactory in close to 90% of the cases. Recovery of strength requires four to six months after regression of the pain of pillar pain type. This surgery has the reputation of being benign and has a complication rate of 0.2–0.5%.

Calcified glomus tumor of the shoulder. A case report.

The authors report a case of calcified glomus tumor of the shoulder in a 54-year-old woman. The nonspecific clinical findings and the noncharacteristic imaging results made diagnosis of this tumor impossible before surgery. The diagnosis was confirmed by a biopsy. The outcome after surgical resection was excellent.

Comparative clinical study of locking screws versus smooth locking pegs in volar plating of distal radius fractures

The present study was performed to test the null hypothesis on no difference in stability of fixation after volar plating of intra-articular distal radius fractures (AO C2-C3) with either locking smooth pegs or locking screws in a clinical setting. A retrospective evaluation included adult patients with C2-C3 AO fractures treated with a volar plate with locking smooth pegs or locking screws. Radiographic assessment was performed to evaluate extra- and intra-articular parameters in the early postoperative period and after bone union. Twenty-seven consecutive patients were included. Thirteen cases had fixation with locking screws and 14 had fixation with locking smooth pegs. Both groups had bone fragment displacement after fixation. However, there were no significant differences between the groups either in extra- or intra-articular parameters defined by Kreder et al. (1996). Our study shows that, in a clinical setting, there is no difference in stability fixation between locking screws or smooth locking pegs in C2-C3 distal radius fractures.

Chronic scapholunate dissociation: ligament reconstruction combining a new extensor carpi radialis longus tenodesis and a dorsal intercarpal ligament capsulodesis.

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.

Open reduction and internal fixation versus prosthetic replacement for complex fractures of the radial head.

c m t o a g e 2 5 e o e s HE PATIENT 50-year-old man had a posterior Monteggia fracture islocation after a fall he took while playing soccer Fig. 1). Physical examination showed a swollen, echymotic, deformed, and painful upper dominant exremity. No neurovascular compromise was noted. Afer clinical and radiographic examination, a proximal hird metaphyseal ulna fracture and a dislocated, cominuted fracture of the radial head were diagnosed. The racture was reduced and immobilized in a splint.

Dynamic splint for the treatment of stiff elbow

Background The purpose of this paper is to retrospectively evaluate the results of the treatment of elbow stiffness with the use of dynamic splints. Methods We included 17 patients with stable and congruent joints, with a range of motion of 100 degrees or less who had not responded to the rehabilitation program. Average previous mobility was 108–42 degrees, with a total arc of 66 degrees. The splints consist of an articulated brace with springs. On average their use began 94 days after surgery or trauma and continued for 86 days. Statistical analysis was performed. Average follow-up was 18 months. Results Postoperative mobility was 126–19 degrees, with a total arc of 107 degrees. Motion increased an average of 41 degrees. Six patients failed to recover a functional arc of motion. Conclusion Our results suggest that dynamic splints are useful in the treatment of elbow stiffness. We achieved an average improvement of 41° in the arc of motion, which in many cases has rendered arthrolysis unnecessary. Tailoring the splint to the individual patient is very important since its usage must be prolonged in order to achieve plastic deformity through the principle of progressive stretching.