Manuel F. DaSilva

Management of Lateral Epicondylitis: Current Concepts

Abstract Lateral epicondylitis, or tennis elbow, is a common cause of elbow pain in the general population. Traditionally, lateral epicondylitis has been attributed to degeneration of the extensor carpi radialis brevis origin, although the underlying collateral ligamentous complex and joint capsule also have been implicated. Nonsurgical treatment, the mainstay of management, involves a myriad of options, including rest, nonsteroidal anti‐inflammatory drugs, physical therapy, cortisone, blood and botulinum toxin injections, supportive forearm bracing, and local modalities. For patients with recalcitrant disease, the traditional open débridement technique has been modified by multiple surgeons, with others relying on arthroscopic or even percutaneous procedures. Without a standard protocol (nonsurgical or surgical), surgeons need to keep abreast of established and evolving treatment options to effectively treat patients with lateral epicondylitis.

Anatomy of the palmar cutaneous branch of the median nerve: Clinical significance†

A detailed anatomic, histologic, and immunohistochemical study of the palmar cutaneous branch of the median nerve (PCBMN) and its distal arborization was undertaken on 12 fresh human cadaveric hands. Small unmyelinated fibers terminated in the superficial loose connective tissue of the transverse carpal ligament. There were no nerve fibers detected in the deep, dense collagen aspect of the ligament. Based on these findings, during open carpal tunnel release, the skin incision should be placed along the axis of the ring finger to avoid injury to the superficial branches of the PCBMN. When open release is used, the very small terminal branches in the loose tissue of the ligament will be transected; this may in part be responsible for postoperative soft tissue pain. For endoscopic releases, some risk for transection of the main trunk of the PCBMN at the proximal incision exists. Repeated passes of the endoscopic knife should be avoided in an attempt to limit damage to the small fibers in the superficial aspect of the ligament.

Nerve Injuries of the Elbow, Wrist, and Hand in Athletes

Upper extremity compression neuropathies are fairly rare in athletes. Initially, most can be managed conservatively. These conditions can follow direct contusion of the tissues that overlay these peripheral nerves or can result from vigorous, repetitive, athletic activity leading to tissue swelling and ischemia with nerve compression symptoms. A complete history and physical examination, including a neurologic examination, should be paramount when treating athletes with upper extremity injuries. Early diagnosis and treatment with conservative measures such as splinting, rest, activity modification, and medications can afford the athlete an earlier return to sports. Surgery can be employed when conservative treatment fails and a specific diagnosis has been ascertained.

Arthroscopic Treatment of Lateral Epicondylitis

Lateral epicondylitis refractory to conservative care can be effectively treated by arthroscopic release of the extensor carpi radialis brevis origin. Advantages to the technique include the ability to address other intra-articular sources of pain (capsular tears, radiocapitellar plica, etc.), a potentially faster return to work and sports, and a smaller incision. This article provides step-by-step descriptions and illustrations of the surgical technique.

Arthroscopic technique for medial epicondylitis: technique and safety analysis.

PURPOSE The goals of this study are to report on a novel arthroscopic technique for the treatment of medial epicondylitis and to further describe the anatomic relations between the site of arthroscopic debridement and both the ulnar nerve and medial collateral ligament (MCL) complex. METHODS Arthroscopic debridement of the medial epicondyle was performed on 8 fresh-frozen cadaveric specimens. Each specimen was dissected, and the shortest distance from the debridement site to both the ulnar nerve and MCL complex was measured with a 3-dimensional motion-tracking system. RESULTS The mean distance between the debridement site and the ulnar nerve was 20.8 mm (range, 14.4 to 25.1 mm), and the mean distance between the medial debridement site and the origin of the anterior bundle of the MCL was 8.3 mm (range, 5.9 to 10.4 mm). CONCLUSIONS Our results suggest that arthroscopic debridement of the medial epicondyle can be performed with low risk of injury to the ulnar nerve or MCL complex. CLINICAL RELEVANCE This cadaveric study indicates a potential role for elbow arthroscopy in the surgical management of refractory medial epicondylitis.

Trends in Revision Elbow Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers.

PURPOSE To determine the frequency of revision elbow ulnar collateral ligament (UCL) reconstruction in professional baseball pitchers. METHODS Data were collected on 271 professional baseball pitchers who underwent primary UCL reconstruction. Each player was evaluated retrospectively for occurrence of revision UCL reconstructive surgery to treat failed primary reconstruction. Data on players who underwent revision UCL reconstruction were compiled to determine total surgical revision incidence and revision rate by year. The incidence of early revision was analyzed for trends. Average career length after primary UCL reconstruction was calculated and compared with that of players who underwent revision surgery. Logistic regression analysis was performed to assess risk factors for revision including handedness, pitching role, and age at the time of primary reconstruction. RESULTS Between 1974 and 2014, the annual incidence of primary UCL reconstructions among professional pitchers increased, while the proportion of cases being revised per year decreased. Of the 271 pitchers included in the study, 40 (15%) required at least 1 revision procedure during their playing career. Three cases required a second UCL revision reconstruction. The average time from primary surgery to revision was 5.2 ± 3.2 years (range, 1-13 years). The average length of career following primary reconstruction for all players was 4.9 ± 4.3 years (range, 0-22 years). The average length of career following revision UCL reconstruction was 2.5 ± 2.4 years (range, 0-8 years). No risk factors for needing revision UCL reconstruction were identified. CONCLUSIONS The incidence of primary UCL reconstructions among professional pitchers is increasing; however, the rate of primary reconstructions requiring revision is decreasing. Explanations for the decreased revision rate may include improved surgical technique and improved rehabilitation protocols. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Malignant ecrrine poroma of the hand: A case report

Carcinoma of sweat glands is a very rare neoplasm that is difficult to diagnose clinically and histologically. This report presents a case of malignant eccrine poroma of the hand which is a distinct histologic subtype of sweat gland carcinoma with a high local recurrence rate. A distal radial artery based forearem flap was used to provide soft tissue coverage

Methylene blue-enhanced arthroscopic resection of dorsal wrist ganglions.

The ganglion is the most common soft tissue mass of the hand and wrist. Over the past 10 to 15 years, there has been a growing interest in arthroscopic treatment of dorsal wrist ganglions. Proposed advantages of arthroscopy include greater motion (particularly wrist flexion), improved cosmesis, and potential to identify/treat other intra-articular pathology. Despite the documented clinical success of arthroscopic ganglion excision, limitations include inconsistent identification of the ganglion stalk. Our described technique offers a means by which to improve visualization of the ganglion stalk intra-articularly to produce a more effective and efficient arthroscopic ganglion excision. During the procedure, a small volume of methylene blue solution is injected into the cyst. Its communication with the joint is apparent arthroscopically, thus identifying the location of the stalk. With the ability to precisely identify the ganglion stalk using an injection of methylene blue, the surgeon can direct the arthroscopic debridement toward the appropriate pathologic tissue. Unnecessary debridement of uninvolved tissue can be avoided with the technique. This also allows for optimal portal placement and, in particular, indicates whether a midcarpal portal should be employed. This should result in fewer recurrences, decreased operative time, and less iatrogenic injury.

Triangular Fibrocartilage Complex

The triangular fibrocartilage complex is a multifaceted ligamentous structure providing support to the ulnocarpal articulation. Improved understanding of the complicated anatomy of the triangular fibrocartilage complex coupled with recent advances in surgical techniques will improve orthopaedic care. The triangular fibrocartilage complex supports the ulnar side of the wrist, provides stability to the distal radioulnar joint, and is the most common source of ulnar-sided wrist pain when injured1-3. Knowledge of the anatomy, biomechanics, and pathology of the triangular fibrocartilage complex has increased greatly over the last three decades, leading to increased awareness of this structure among physicians4. In one cadaveric study, more than half (thirty-two) of sixty-one specimens had perforations of the triangular fibrocartilage complex5. All specimens with tears had evidence of damage to the lunate and/or distal ulnar cartilage, illustrating that damage to the triangular fibrocartilage complex and subsequent instability of the distal radioulnar joint can be associated with ulnolunate abutment5. This was reiterated by Lee et al., who found that the majority (fifty-eight) of ninety-six cadaveric specimens (average age at the time of death, seventy-five years) had disruption …

Arthroscopic reduction and percutaneous pinning of a radiocarpal dislocation: a case report.

Radiocarpal dislocations are complex injuries characterized by high-energy shear and rotational forces to the wrist, often combined with a fracture of the distal part of the radius or ulna1. They often present as open fractures and can be complicated by soft-tissue injuries such as intercarpal and radiocarpal ligament tears and nerve injuries1-3. Current management of radiocarpal dislocations is based on treatment principles described by Ilyas and Mudgal, which include concentric reduction of the radiocarpal joint, identification and appropriate treatment of intercarpal ligament injuries, and stable repair of the osseous-ligamentous avulsions1. While these injuries were previously managed with the use of closed reduction and immobilization4-7, authors of recent reports have recognized the instability of these complex injuries and have described treatment algorithms using open reduction and internal fixation1. We report a case of ulnar radiocarpal wrist dislocation treated with wrist arthroscopy and percutaneous pinning without repair of the extrinsic wrist ligaments. A twenty-three-year-old right-hand-dominant male presented with pain in the left wrist one week after a motorcycle accident. He had no neurological symptoms and no pain in other extremities. The patients medical and surgical histories were noncontributory. The findings on the neurovascular examination of the left hand were normal, and the patient was able to actively flex and extend the wrist approximately 20° with extreme pain. There was diffuse swelling about the wrist and pain with passive wrist motion. There was diffuse tenderness about the radiocarpal and midcarpal joints, and the patient was unable to tolerate any instability examinations secondary to severe pain. He had painless motion of the ipsilateral elbow and shoulder. Radiographs of the wrist demonstrated an ulnar styloid fracture, triquetral avulsion fracture, and ulnar shift of the carpus that was approximately 3.3 mm more …