Michelle G. Carlson

Volar Plate Position and Flexor Tendon Rupture Following Distal Radius Fracture Fixation

PURPOSE To determine whether there were differences between plate position in patients who had postoperative flexor tendon ruptures following volar plate fixation of distal radius fractures and those who did not. METHODS Three blinded reviewers measured the volar plate prominence and position on the lateral radiographs of 8 patients treated for flexor tendon ruptures and 17 matched control patients without ruptures following distal radius fracture fixation. We graded plate prominence using the Soong grading system, and we measured the distances between the plate and both the volar critical line and the volar rim of the distal radius. RESULTS A higher Soong grade was associated with flexor tendon rupture. Patients with ruptures had plates that were more prominent volarly and more distal than matched controls without ruptures. Plate prominence projecting greater than 2.0 mm volar to the critical line had a sensitivity of 0.88, a specificity of 0.82, and positive and negative predictive values of 0.70 and 0.93, respectively, for tendon ruptures. Plate position distal to 3.0 mm from the volar rim had a sensitivity of 0.88, a specificity of 0.94, and positive and negative predictive values of 0.88 and 0.94, respectively, for tendon ruptures. CONCLUSIONS We identified plate positions associated with attritional flexor tendon rupture following distal radius fracture fixation with volar plates. To decrease rupture risk, we recommend considering elective hardware removal after union in symptomatic patients with plate prominence greater than 2.0 mm volar to the critical line or plate position within 3.0 mm of the volar rim. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Removal of Locked Volar Plates After Distal Radius Fractures

PURPOSE We present our experience with removal of locked volar distal radius plates and screws and note the indications for removal, types of plates removed, completeness of hardware removal, and complications occurring during plate removal. METHODS We reviewed all distal radial volar locking plates removed at our institution from 2004 to 2009. A total of 28 patients operated on by 5 hand surgeons were identified. We gathered information regarding the incidence of successful removal of hardware and operative findings in cases of difficult removal of hardware. RESULTS A total of 28 patients (16 women, 12 men) underwent removal of locked volar distal radius plates from 2004 to 2009. The mean length of implantation was 63 weeks (range, 3-223 wk). Reasons for removal of hardware included tenosynovitis, tendon rupture, pain, and prominent or intra-articular hardware. Of 28 cases of locked volar plate removal, 2 had complications. In the first case, a screw was cross-threaded in an earlier generation DVR Hand Innovations plate implanted in 2003. The plate and screw were removed by rotating them out as 1 unit. In the second case, in which the current generation DVR Hand Innovations plate was implanted in 2007, the recess in the screw head had been stripped on insertion. The plate was cut and the remaining fragment of plate and screw were removed together. Despite these difficulties, hardware was successfully removed completely in 28 patients. CONCLUSIONS This case series highlights the result that all removals of locked volar plates were successful. There were 2 complications, and strategies for removal are described. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Thumb Metacarpophalangeal Joint Collateral Ligament Injury Management

The thumb collateral ligaments at the metacarpophalangeal joint are important to the elite athlete for precision grip and pinch. Injuries to these ligaments can result in pain and instability and are seen at a higher frequency at the elite level. Whereas the collateral ligament tears used to be associated primarily with recreational skiers injury, these injuries have been reported with increasing frequency in major professional sports. The ulnar collateral and radial collateral ligament injuries of the thumb occur through different mechanisms and are described in separate sections given the differences in their anatomy.

Anatomy of the Thumb Metacarpophalangeal Ulnar and Radial Collateral Ligaments

PURPOSE To describe the origin and insertion of the ulnar (UCL) and radial collateral ligaments (RCL) of the thumb metacarpophalangeal (MCP) joint. METHODS We dissected 18 UCLs and 18 RCLs from fresh-frozen human cadaveric thumbs. We removed all soft tissue overlying the MCP joint, isolating the proper collateral ligaments. We detached the collateral ligaments from the bone while marking their origin and insertion points and measured these attachment sites in relation to bony landmarks by digital photo analysis. RESULTS The center of the UCL origin at the metacarpal was 4.2 mm from the dorsal surface and 5.3 mm from the articular surface. The dorsal aspect of the metacarpal origin site was 2.1 mm from the dorsal edge of the metacarpal. The center of the phalangeal insertion was 2.8 mm from the volar surface and 3.4 mm from the articular surface. The volar aspect of the phalangeal insertion site was 0.7 mm from the volar edge of the phalanx. The center of the RCL origin at the metacarpal was 3.5 mm from the dorsal surface and 3.3 mm from the articular surface. The dorsal aspect of the metacarpal origin site was 1.5 mm from the dorsal edge of the metacarpal. The center of the phalangeal insertion was 2.8 mm from the volar surface and 2.6 mm from the articular surface. The volar aspect of the phalangeal insertion site was 0.5 mm from the volar edge of the phalanx. CONCLUSIONS Our study accurately defined the origin and insertion sites of the UCL and RCL of the thumb MCP joint. CLINICAL RELEVANCE An accurate definition of the anatomical origin and insertion points of the thumb MCP UCL and RCL may allow for more successful surgical repair and reconstruction.

Extensor Tendon Centralization at the Metacarpophalangeal Joint: Surgical Technique

Injury to the extensor hood at the level of the dorsal metacarpophalangeal joint with instability and subluxation of the extensor tendon might require surgical treatment after failing conservative methods. Surgical techniques for chronic injuries have used local tissue or nearby tendon slips as grafts for tendon realignment, with or without soft tissue release and imbrication. Here we present a technique that creates a bone tunnel for a graft that is sutured upon itself and effectively creates a new pulley.

Management of nonunion following surgical management of scaphoid fractures: current concepts.

&NA; Management of scaphoid nonunion after failed surgery for acute scaphoid fracture presents a unique treatment challenge. Prior surgery complicates patient evaluation and increases the technical difficulty of future procedures. Healing of nonunion is crucial to prevent carpal collapse and progressive arthritis. A thorough workup is required to identify technical factors or treatment decisions that may have resulted in a poor outcome after initial fixation attempts. CT is particularly useful for characterizing nonunion and planning revision surgery. Several studies have described the use of bone grafts and fixation devices for scaphoid nonunion repair, including nonvascularized and vascularized bone grafts, screws, pins, and plates. Reliable rates of union have been achieved using nonvascularized bone graft supplemented with screw or wire fixation, particularly in the absence of osteonecrosis. Although vascularized grafts are more technically challenging, they improve the odds of union in the setting of osteonecrosis.

Opinions Regarding the Management of Hand and Wrist Injuries in Elite Athletes

Injuries to the hand and wrist are commonly encountered in athletes. Decisions regarding the most appropriate treatment, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. Little recognition in the literature exists regarding the need for a different approach when treating these injuries in elite athletes and the timing to return to play. This study explored the complexities of treating hand and wrist injuries in the elite athlete. Thirty-seven consultant hand surgeons for teams in the National Football League, National Basketball Association, and Major League Baseball completed a brief electronic survey about the management of 10 common hand injuries. Notable variability existed in responses for initial management, return to protected play, and return to unprotected play for all injuries, aside from near consensus agreement (94%) that elite athletes with stable proximal interphalangeal dislocations could immediately return to protected play. Basketball surgeons were less likely to recommend early return to protected play than non-basketball surgeons. Baseball surgeons were more likely to recommend early unprotected play after scaphoid fixation. Football surgeons were more likely to recommend earlier return to protected play after thumb ulnar collateral ligament injuries, whereas basketball surgeons were less likely to recommend earlier return to protected play. This study demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The findings emphasize the need to individually tailor treatment decisions to the patients desires and demands, particularly in high-performance athletes.

Opportunistic Osteoporosis Screening— Gleaning Additional Information from Diagnostic Wrist CT Scans

BACKGROUND Although screening for and treating osteoporosis can prevent subsequent fractures, the rates of such interventions are low following a distal radial fracture. One potential method for identifying metabolic bone disease is via Hounsfield unit (HU) measurements from diagnostic computed tomography (CT) scans. We hypothesized that HU values of the distal aspect of the radius could be used to assess local bone quality and would be predictive of distal radial fracture risk, thereby allowing the identification of patients in need of further management. METHODS Measurements of bone mineral density (BMD) were made for 100 patients on the basis of HU values of cancellous portions of the distal aspect of the radius, the ulnar head, and the capitate. The HU values in twenty-five male and twenty-five female patients with an acute distal radial fracture documented on CT were compared with those of age and sex-matched control patients who had a CT scan obtained for other indications. RESULTS Among the control patients, HU values decreased as age increased. When assessed on the basis of sex, both male and female patients with a distal radial fracture had significantly lower regional BMD compared with nonfracture control patients. A distal radial HU value of 218 for females and 246 for males optimized sensitivity and specificity; values below this threshold were associated with an increased risk of distal radial fracture. CONCLUSIONS HU measurements can be obtained from any diagnostic CT scan using modern software programs and can be obtained by physicians in the office setting with minimal effort and at no additional cost or radiation exposure to the patient. Regardless of imaging indications, we suggest that patients with HU values below the identified thresholds be considered for further metabolic bone disease work-up, such as additional imaging, laboratory assessments, the initiation of osteoporosis treatment, or appropriate referral.

Impact of video review on surgical procedure determination for patients with cerebral palsy.

PURPOSE Evaluation of patients with cerebral palsy is complex and variable. Several examinations, including video analysis, are necessary as part of the surgical planning process. Videotaped evaluation of the upper extremity in children with cerebral palsy has been used as an objective assessment of functional ability and deformity. The effect of review of these videotaped evaluations on altering the initially proposed surgical plan has not been evaluated. METHODS This is a retrospective study completed through a chart review. Inclusion criteria were all patients with cerebral palsy having upper extremity surgical consultation with the primary investigator (M.G.C.) between 1995 and 2005, having at least 2 presurgical consultations, completing a videotaped evaluation, and proceeding to surgery. Of 167 new patients, 94 patients, having 430 procedures, were eligible for the study. Five distinct anatomical areas (elbow, forearm, wrist, digit, and thumb) were delineated. RESULTS Changes to the initial surgical plan based on a review of the videotaped evaluation were made for 77 patients (138 procedures) and carried through to surgery for 68 patients (108 procedures). Those procedure changes that carried through to surgery most often involved the thumb, wrist, and digit, as compared to the elbow and forearm. CONCLUSIONS Videotaping evaluations allows for more precise understanding of ability and improves diagnosis. Changes to the initial presurgical plan were made in 77 patients (72%) after videotaped evaluation, most commonly for procedures addressing the wrist, digit, and thumb.

Early Results of Surgical Intervention for Elbow Deformity in Cerebral Palsy Based on Degree of Contracture

PURPOSE Elbow flexion posture, caused by spasticity of the muscles on the anterior surface of the elbow, is the most common elbow deformity seen in patients with cerebral palsy. This study retrospectively evaluated early results of 2 surgical interventions for elbow flexion deformities based on degree of contracture. We hypothesized that by guiding surgical treatment to degree of preoperative contracture, elbow extension and flexion posture angle at ambulation could be improved while preserving maximum flexion. METHODS Eighty-six patients (90 elbows) were treated for elbow spasticity due to cerebral palsy. Seventy-one patients (74 elbows) were available for follow-up. Fifty-seven patients with fixed elbow contractures less than 45° were surgically treated with a partial elbow muscle lengthening, which included partial lengthening of the biceps and brachialis and proximal release of the brachioradialis. Fourteen patients (17 elbows) with fixed elbow contractures ≥ 45° had a more extensive full elbow release, with biceps z-lengthening, partial brachialis myotomy, and brachioradialis proximal release. RESULTS Age at surgery averaged 10 years (range, 3-20 y) for partial lengthening and 14 years (range, 5-20 y) for full elbow release. Follow-up averaged 22 months (range, 7-144 mo) for partial lengthening and 18 months (range, 6-51 mo) for full elbow release. Both groups achieved meaningful improvement in flexion posture angle at ambulation, active and passive extension, and total range of motion. Elbow flexion posture angle at ambulation improved by 57° and active extension increased 17° in the partial lengthening group, with a 4° loss of active flexion. In the full elbow release group, elbow flexion posture angle at ambulation improved 51° and active extension improved 38°, with a loss of 19° of active flexion. CONCLUSIONS Surgical treatment of spastic elbow flexion in cerebral palsy can improve deformity. We obtained excellent results by guiding the surgical intervention by the amount of preoperative elbow contracture. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.