Nicola A. DeAngelis

Use of the trauma pelvic orthotic device (T-POD) for provisional stabilisation of anterior-posterior compression type pelvic fractures: a cadaveric study.

OBJECTIVE To demonstrate that a commercially available pelvic binder the trauma pelvic orthotic device (T-POD) is an effective way to provisionally stabilise anterior-posterior compression type pelvic injuries. METHODS Rotationally unstable pelvic injuries were created in 12 non-embalmed human cadaveric specimens. Each pelvis was then stabilised first with a standard bed sheet wrapped circumferentially around the pelvis and held in place with a clamp. After recreating the symphyseal diastasis, the pelvis was stabilised with the T-POD. Reduction of the symphyseal diastasis was assessed by comparing measurements obtained via pre- and post-stabilisation AP radiographs. RESULTS The mean symphyseal diastasis was reduced from 39.3mm (95% CI 30.95-47.55) to 17.4mm (95% CI -0.14 to 34.98) with the bed sheet, and to 7.1mm (95% CI -2.19 to 16.35) with the T-POD. CONCLUSIONS Although both a circumferential sheet and the T-POD were able to decrease symphyseal diastasis consistently, only the T-POD showed a statistically significant improvement in diastasis when compared to injury measurements. In 75% of the cadaveric specimens (9 of 12), the T-POD was able to reduce the symphysis to normal (<10mm diastasis). Both a circumferential sheet and the T-POD are effective in provisionally stabilising Burgess and Young anterior-posterior compression II type pelvic injuries, but the T-POD is more effective in reducing symphyseal diastasis.

Does Medial Tenderness Predict Deep Deltoid Ligament Incompetence in Supination-External Rotation Type Ankle Fractures?

Objective: To identify whether medial tenderness is a predictor of deep deltoid ligament incompetence in supination-external rotation ankle fractures. Design: All Weber B lateral malleolar fractures with normal medial clear space over a 9 month period were prospectively included in the study. Fracture patterns not consistent with a supination-external rotation mechanism were excluded. Setting: High-volume tertiary care referral center and Level I trauma center. Patients/Participants: Fifty-five skeletally mature patients with a Weber B lateral malleolar fracture and normal medial clear space presenting to our institution were included. Intervention: All study patients had ankle anteroposterior, lateral, and mortise radiographs. Each patient was seen and evaluated by an orthopedic specialist and the mechanism of injury was recorded. Each patient was assessed for tenderness to palpation in the region of the deltoid ligament and then had an external rotation stress mortise radiograph. Main Outcome Measure: Correlating medial tenderness with deep deltoid competence as measured by stress radiographs. Results: Thirteen patients (23.6%) were tender medially and had a positive external rotation stress radiograph. Thirteen patients (23.6%) were tender medially and had a negative external rotation stress radiograph. Nineteen patients (34.5%) were nontender medially and had a negative external rotation stress radiograph. Ten patients (18.2%) were nontender medially and had a positive external rotation stress radiograph. We calculated a χ2 statistic of 2.37 as well as the associated P value of 0.12. Medial tenderness as a measure of deep deltoid ligament incompetence had a sensitivity of 57%, a specificity of 59%, a positive predictive value of 50%, a negative predictive value of 66%, and an accuracy of 42%. Conclusion: There was no statistical significance between the presence of medial tenderness and deep deltoid ligament incompetence. There is a 25% chance of the fracture in question with medial tenderness having a positive external rotation stress and a 25% chance the fracture with no medial tenderness having a positive stress test. Medial tenderness in a Weber B lateral ankle fracture with a normal clear space on standard plain radiographs does not ensure the presence of a positive external rotation stress test.

Anatomy of the superficial peroneal nerve in relation to fixation of tibia fractures with the less invasive stabilization system.

Objective: To examine the danger to the superficial peroneal nerve during percutaneous screw placement in the distal holes of the 13-hole proximal tibia Less Invasive Stabilization System plate in a cadaver. Design: Anatomic study. Setting: Medical school anatomy laboratory. Interventions: Fourteen adult cadaveric lower extremities were used. A 13-hole proximal tibia Less Invasive Stabilization System plate was placed as described by the manufacturer. Dissection of the superficial peroneal nerve was performed following localization of screw holes 7 through 13 using insertion sleeves, centering sleeves, and 2.0-mm Kirschner wires passed through the insertion guide. Results: The average distance from the superficial peroneal nerve to the center of holes 11, 12, and 13 was 10.0 mm (range 0–21, standard deviation 5.6), 6.8 mm (range 0–16, standard deviation 4.3), and 2.7 mm (0–11, standard deviation 3.7), respectively. In 12 of 14 legs (86%), the superficial peroneal nerve was 5.0 mm or less from the center of hole 13. The nerve was touching the guide wire at hole 11 in 1 specimen (7%), at hole 12 in 2 specimens (14%), and at hole 13 in 6 specimens (43%). In 1 specimen (7%), the guide wire pierced the superficial peroneal nerve at hole 13. Conclusion: These findings suggest that the superficial peroneal nerve is at significant risk during percutaneous screw placement in holes 11 through 13 of the 13-hole proximal tibia Less Invasive Stabilization System plate. Use of a larger incision and careful dissection down to the plate in this region may minimize the risk of damage to the nerve.

The proximal biceps tendon: tricks and pearls.

The diagnosis and treatment of proximal biceps tendon injuries continue to be a challenge. The difficulty lies on determining if there is isolated biceps pathology versus concomitant rotator cuff tears or instability. Imaging modalities, such as magnetic resonance imaging, continue to provide us with the extra tool to help us confirm our suspicion of additional pathology. Symptomatic biceps tendon tears can undergo debridement, tenotomy, or tenodesis if nonoperative measures fail to provide relief. Reports from performing a biceps tenotomy often give similar functional outcomes compared with tenodesis. Cosmetic deformity on the lateral arm may be noted with tenodesis and initial fatigue. Tenodesis may subject the patient to a longer rehabilitation process and increased pain. The decision of which one should be performed lies between the physician and the patients expectations.

Treatment of Distal Biceps Tendon Ruptures Using a Single-Incision Technique and a Bio-Tenodesis Screw

No consensus exists in the literature on the optimal operative treatment method for distal biceps tendon ruptures. It is our hypothesis that a single-incision technique with a poly-L-lactide Bio-Tenodesis screw (Arthrex, Inc, Naples, Florida) is a safe and effective method for operative management of distal biceps tendon ruptures, with success and complication rates comparable to previous reports in the literature. This article describes a prospective case series of 29 consecutive patients (30 operations) managed by the same surgeon over 34 months. Average follow-up was 19.6 months. Two patients were lost to follow-up. Elbow range of motion (ROM) and strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and SF-12 score were measured at various time points up to 2 years. All patients had full extension and supination. Supination and flexion strength was at least 4/5 in all patients. Mean DASH, SF-12 Physical Component (PCS), and SF-12 Mental Component (MCS) scores were 5.86 (range, 0-16.67), 50.35 (range, 30.4-60.1), and 57.15 (range, 41.7-64.4), respectively. These scores are comparable to normative values reported by the American Academy of Orthopaedic Surgeons. Complication rates were similar to those previously reported in the literature. This type of fixation allowed for early mobilization of the operative arm. Our study demonstrates that use of a tenodesis screw for distal biceps repair results in DASH and SF-12 scores comparable to the norm for the general population with complications similar to those seen in past studies. In addition, biomechanical studies suggest that the repair is strong enough to allow early ROM, and the fixation technique may allow for more anatomic positioning of the distal biceps along the ulnar border of the bicipital tuberosity.

Congenital instability of the shoulder joint: assessment and treatment options.

UNLABELLED Congenital instability of the shoulder is a form of multidirectional instability not caused by a traumatic event. It is believed that excess laxity may be responsible for an overly elastic capsule and, therefore, can contribute to multidirectional instability. Minor microtraumatic events can progressively lead to the development of pain and lead to instability. The current preferred treatment is largely nonoperative with extensive rehabilitation of the dynamic restraints of the shoulder complex. In recalcitrant cases, operative intervention to restore stability may be necessary. It is of paramount importance to notice the directions of instability and to address each of them. Surgical procedures include open capsular shift, as well as arthroscopic capsular plication. Because multidirectional instability can be difficult to diagnose, this article will attempt to provide the clinician with a better understanding of the pathophysiology involved in this condition, the necessary steps for diagnosis, and considerations for treatment. A comprehensive guide to both nonoperative and operative treatment is reviewed in this article, as well as the surgical techniques used to decrease the capsular volume. LEVEL OF EVIDENCE Level 5.

Understanding the superior clear space in the adult ankle

Background: The width of the medial clear space often is used to determine the integrity of the deltoid ligament, the primary medial stabilizer of the ankle joint. The normal clinical relationship of the superior clear space to the medial clear space is not well described. This investigation sought to determine if the superior clear space constitutes an accurate point of comparison for the medial clear space and a means for assessing ligamentous stability in an adult ankle. Methods: A retrospective review of consecutive ankle radiographs for a 4-month period of time was completed using a university-based radiology database. Using a digitally calibrated ruler, the widths of the medial and superior clear spaces were measured on the mortise view. These values were compared using a Students t-test. Results: Digital radiographs of 564 consecutive ankles were reviewed retrospectively and 94 cases were without evidence of trauma, surgery, or degenerative disease. The medial and superior clear spaces were measured on the mortise view and found to be 2.7 mm (standard deviation 0.5; range 1.3 mm to 4.3 mm; 95% confidence interval 1.7 mm to 3.8 mm) and 3.6 mm (standard deviation 0.6; 2.0 to 5.3; CI 2.4 mm to 4.7 mm), respectively. The average absolute difference was 0.9 mm (standard deviation 0.5; −0.7 to 1.5; CI −0.1 mm to 1.8 mm) and in 92 of 94 ankles (98%), the superior clear space was greater than or equal to the medial clear space. Conclusions: Understanding the normal radiographic relationship of the superior and medial clear spaces may help in the diagnosis of ligamentous instability in the ankle and may obviate the need for additional diagnostic tests.

Three-part head-splitting proximal humerus fracture through a unicameral bone cyst

Unicameral bone cysts are rare in adults and are most often found incidentally on radiographs. However, they can persist from the adolescent period and may be present in locations that predispose to or exacerbate fractures.This article describes a case of a healthy 40-year-old woman who sustained a proximal humerus trauma that involved a large unicameral bone cyst, resulting in a 3-part head-splitting fracture. The epiphyseal location of the cyst contributed to the severity and extent of the fracture that resulted from a simple fall. Given the age of the patient, open reduction and internal fixation with a locking plate and lag screws was performed. The patient chose open reduction and internal fixation to preserve a hemiarthroplasty procedure in case of future revision. Successful humeral head reconstruction was achieved, and the patient fully recovered. One year postoperatively, the patient underwent arthroscopic debridement to alleviate subjective stiffness and decreased range of motion.Multipart head-splitting fractures require complex repair strategies. The gold standard for the treatment of these injuries is hemiarthroplasty. However, the decision process is difficult in a young patient given the average survival of autoplastic prostheses and the added difficulty of later revision. The current case demonstrates the complexity of decision making resulting from a rare injury in a young, healthy patient and shows that open reduction and internal fixation can provide acceptable reconstruction in such situations.