Perry C. Turner

Treatment of partial distal biceps tendon tears.

Partial rupture of the distal biceps tendon exhibits features similar to that of complete disruption, including acute antecubital pain, weakness of elbow flexion, and forearm supination, and differs only in the fact that the biceps tendon is still palpable in the partial rupture. There are 2 etiologies, first acute traumatic (such as a sudden eccentric contracture) and second, chronic degenerative tendon disease. For accurate diagnosis, a high index of suspicion must be employed. Initial investigations should include plain x-ray and a magnetic resonance scan. Partial tears <50% may be treated with nonoperative management or with surgical debridement of the surrounding synovitis. Tears >50% should be treated with division of the remaining tendon and surgical repair of the entire tendon as a single unit. Surgical endoscopy provides the ability to further quantify the extent of a distal biceps tear and to treat with debridement. This technique, however, should only be used in experienced hands.

Using computed tomography to assist with diagnosis of avascular necrosis complicating chronic scaphoid nonunion.

PURPOSE The primary aim of our study was to investigate use of long axis computed tomography (CT) in predicting avascular necrosis of the proximal pole of the scaphoid and subsequent fracture nonunion after internal fixation. In addition, we describe a new technique of measuring the position of a scaphoid fracture and provide data on its reproducibility. METHODS Thirty-one patients operated on by the senior author for delayed union or nonunion of scaphoid fracture were included. Preoperative CT scans were independently assessed for increased radiodensity of the proximal pole, converging trabeculae, degree of deformity, comminution, and fracture position. Intraoperative biopsies of the proximal pole were obtained and histologically assessed for evidence of avascular necrosis. The radiologic variables were statistically compared with the histologic findings. The presence of avascular necrosis was also compared with postoperative union status, identified on longitudinal CT scans. RESULTS Preoperative CT features that statistically correlated with histologic evidence of avascular necrosis were increased radiodensity of the proximal pole and the absence of any converging trabeculae between the fracture fragments. The radiologic changes of avascular necrosis and the histologic confirmation of avascular necrosis were associated with persistent nonunion. CONCLUSIONS Preoperative longitudinal CT of scaphoid nonunion is of great value in identifying avascular necrosis and predicting subsequent fracture union. If avascular necrosis is suspected based on preoperative CT, management options include vascularized bone grafts and bone morphogenic protein for younger patients and limited wrist arthrodesis for older patients. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.

Translunate fracture with associated perilunate injury: 3 case reports with introduction of the translunate arc concept.

We report 3 cases of translunate fractures with associated perilunate dislocations (or subluxation). We believe the translunate injury reflects a higher-velocity trauma and produces further destabilization of the carpus when compared with the established greater and lesser arc injuries. A modification to Johnsons perilunate injury classification system is proposed: the addition of a translunate arc injury subgroup, which would include all perilunate injuries with translunate fractures.

Review of imaging of scaphoid fractures

Scaphoid fractures are the most common fractures of the carpus, accounting for 79% of all carpal fractures. Early diagnosis of scaphoid fractures is imperative owing to potential complications following the fracture, including non‐union, avascular necrosis, carpal instability and osteoarthritis. Plain radiography remains the initial imaging modality to assess scaphoid fractures. Magnetic resonance imaging (MRI) is excellent in the detection of clinically suspected, but initially radiographically negative, scaphoid fractures. Cost‐effectiveness analysis studies have demonstrated MRI is effective in this setting. Gadolinium enhanced MRI has been shown to be superior to unenhanced MRI in the detection of avascular necrosis. Computerized tomography scan is the preferred modality to assess the intricacies of scaphoid fracture, including fracture location and deformity, as well as union status. This review paper explores the recent advances in imaging of the scaphoid, with reference also to avascular necrosis and non‐union following a scaphoid fracture.

Effect of scaphoid and triquetrum excision after limited stabilisation on cadaver wrist movement

This study assessed the effect of excision of the scaphoid and triquetrum on the range of motion of the embalmed cadaver wrist joint after midcarpal stabilisation. The range of motion was measured in 12 cadaver wrists before and after stabilisation of the joints between the lunate, capitate, triquetrum and hamate. This was measured again following resection of the scaphoid and then the triquetrum. Scaphoid excision after four-corner stabilisation increased the radioulnar (RU) arc by 12° and the flexion–extension (F–E) arc by 10°. Subsequent excision of the triquetrum, to produce a three-corner stabilisation, further increased the RU arc by 7° and the F–E arc by 6°. Three-corner stabilisation with excision of scaphoid and triquetrum improved wrist motion in embalmed cadavers.

Imaging Recognition of Morphological Variants at the Midcarpal Joint

PURPOSE To compare the imaging methods for identifying the various morphological variations of the articular surfaces at the midcarpal joint. METHODS Thirteen cadaveric wrists were examined by plain neutral anteroposterior radiographs; 2-dimensional computed tomography (CT); 3-dimensional CT reconstruction, and 3-tesla magnetic resonance imaging (MRI). Carpal measurements were performed, and the parameters that defined the scaphoid, lunate, hamate, and capitate morphological types were investigated, with dissection being used as the definitive measure of morphology. The dissection findings were compared to the results of each imaging technique to determine the accuracy of morphological determination from each technique. RESULTS Lunate type was the most accurately identified morphological variant amongst all imaging techniques. Lunate type was most accurately determined from coronal MRI. A lunate with a small, cartilaginous ulnar facet (intermediate type) could be differentiated only by coronal MRI and dissection. Scaphoid type could not be determined accurately using any of the imaging modalities described. Capitate type was most accurately determined from coronal MRI. However, flat and spherical-type capitates could not be routinely differentiated from V-shaped capitates. Hamate type was most accurately determined from 3-dimensional CT reconstruction. CONCLUSIONS Accurate identification of carpal bone morphology is required to improve our understanding of carpal mechanics and pathology. Not all morphological features can be identified radiographically. Direct visualization is required to differentiate types of scaphoid, and to differentiate V-type capitates. MRI provides the most accurate identification of lunate type, and 3-dimensional CT provides the best method of differentiating hamate types.

Arthroscopic dorsal capsular release in the wrist: a new technique.

Wrist stiffness is a multifactorial condition that is debilitating for those which it affects. Although good results have been achieved in the past with aggressive physiotherapy and splinting regimens, however, there are some cases that remain refractory to this treatment. In those cases that are caused primarily by arthrofibrosis, arthroscopic surgical release of the capsule is another treatment option. Arthroscopic release of the volar wrist capsule has been previously described. The authors describe this new technique for arthroscopic dorsal capsular release using an intracapsular nylon tape to afford protection to the extensor tendons. They believe that the procedure is relatively safe with a low complication rate as well as good patient outcomes. Although the cohort of patients in whom this procedure is indicated is likely to be small, we feel that it gives the upper-limb surgeon another option for managing this often difficult problem.