Peter J. L. Jebson

MDCT and Radiography of Wrist Fractures: Radiographic Sensitivity and Fracture Patterns

OBJECTIVE The purpose of our study was to determine which wrist fractures are not prospectively diagnosed at radiography using CT as a gold standard and to identify specific fracture patterns. MATERIALS AND METHODS Through a search of radiology records from January 1 to December 31, 2005, 103 consecutive patients were identified as having radiographic and CT examinations of the wrist. After excluding incomplete or nondiagnostic examinations and those with a greater than 6-week interval between imaging studies, the final study group consisted of 61 wrist examinations in 60 patients. Two musculoskeletal radiologists and one emergency radiologist blindly reviewed CT examinations, and each bone (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate, metacarpals, distal radius, distal ulna) was categorized as normal or fractured, with agreement reached by consensus. Each prospective radiographic report was categorized as either normal or fracture/equivocal for each osseous structure. Results were compared using the chi-square and Fishers exact tests. RESULTS In the proximal carpal row, lunate and triquetrum fractures were often radiographically occult (0% and 20%, respectively, detected at radiography); whereas in the distal carpal row, trapezoid, capitate, and hamate fractures were often occult (0%, 0%, and 40% detected at radiography, respectively). Hamate fractures were significantly associated with metacarpal fractures, and distal radius fractures were associated with scaphoid and ulna fractures. CONCLUSION Thirty percent of wrist fractures were not prospectively diagnosed on radiography, suggesting that CT should be considered after a negative radiographic finding if clinically warranted. The location of a dorsal scaphoid avulsion fracture emphasizes the need for specific radiographic views or cross-sectional imaging for diagnosis.

Use of oral vitamin C after fractures of the distal radius.

i t w c C C HERE HAS BEEN considerable debate regarding the effect of vitamin C on the prevention of complex regional pain syndrome (CRPS) in the etting of distal radius fractures. Vitamin C, also nown as ascorbic acid, is a water-soluble organic comound first identified in 1932. Although humans are nable to synthesize vitamin C, it is an essential microutrient in many enzymatic and chemical pathways. itamin C acts as a cofactor for 8 different enzymes hat are involved in collagen hydroxylation, carnitine nd norepinephrine biosynthesis, amidation of peptide ormones, and tyrosine metabolism. In addition, vitain C acts as a powerful chemical reducing agent, or ntioxidant. Vitamin C is found in a large number of vegetables nd fruits (Table 1). The precise amount of vitamin C n a specific vegetable or fruit varies based on serving ize, season, transport, shelf time, storage, and cooking ractices. If an individual consumes 5 standard servings f vegetables and fruit in a day, daily vitamin C intake ill range from 210 to 280 mg. Complex regional pain syndrome, also known as eflex sympathetic dystrophy or algodystrophy, occurs requently after fracture of the distal radius. Although eported incidence varies from one study to another, the ncidence has been reported to be as high as 25% to 7% in prospective investigations. CRPS is characerized by unexplained pain and swelling, vasomotor nstability, and loss of joint mobility. The pathophysilogy of CRPS remains poorly understood. Two landmark, randomized, controlled trials by Zolinger et al. demonstrated that vitamin C reduces the

Fibrous hamartoma of infancy in the hand: A case report

Fibrous hamartoma of infancy (FHI) is a rare, benign tumor. The proximal upper extremity is most commonly involved. A previously unreported case of FHI in the hand is presented.

Current Treatment of Radial Nerve Palsy Following Fracture of the Humeral Shaft

a I c i w n a In B ri ef HE ASSOCIATION BETWEEN radial nerve injury and humeral shaft fracture was described by Berkeley surgeons Holstein and Lewis, who oberved radial nerve palsy in the setting of spiral fracures of the distal third of the humeral shaft wherein the distal bone fragment is always displaced proxially with its proximal end deviated radialward” and hat “the radial nerve is caught in the fracture site.” ubsequent reports have described cases of radial nerve alsy following fractures of the middle third of the shaft f the humerus as well. A recently published anaomical study by Carlan et al. emphasizes that the radial erve is at risk of injury in these 2 regions: (1) along the osterior mid-aspect of the humerus where the nerve ies in direct contact with the periosteum and (2) along he distal lateral humerus where the nerve pierces the ateral intermuscular septum. A recent epidemiological study documented a 9% ncidence of radial nerve injury following humeral shaft racture, whereas a systematic review of the literature oted a 12% incidence. Radial nerve palsy may be ither partial or complete; complete motor loss occurs n approximately 50% of cases. Radial nerve palsy in he setting of humeral shaft fracture can be further lassified as primary or secondary. In primary nerve alsy, loss of function occurs at the time of injury. In econdary nerve palsy, loss of function occurs during he course of treatment. Because prospective randomzed clinical trials have not evaluated treatment of this njury, our clinical decision making has to be based on he empiric evidence garnered from retrospective case eries. In complete primary radial nerve palsy associated

The effect of knee and ankle position on displacement of Achilles tendon ruptures in a cadaveric model. Implications for nonoperative management.

Using a cadaveric model, we evaluated the effect of knee and ankle position on the displacement of the severed ends of an Achilles tendon transected at three different points. In six cadaveric legs the Achilles tendon was severed transversely, then marked with radiopaque wire suture. The distance between the wire markers was measured on radiographs taken in different positions of ankle and knee flexion. Ankle plantar flexion had a statistically significant effect on decreasing the gap between the severed ends of the Achilles tendon. This effect was clinically significant as, on average, the tendon edges were separated more than 20 mm when the ankle was in the neutral position and were apposed when the ankle was in 60° of plantar flexion. With the ankle fixed in 60° of plantar flexion, knee position had no significant effect on the displacement of the severed ends of the Achilles tendon. Overall, the effect of knee flexion was neither statistically significant nor clinically significant, as the increase in displacement of the severed ends of the Achilles tendon was only 3 mm from 0° to 120° of knee flexion. These results suggest that the nonoperative treatment of Achilles tendon ruptures requires immobilization in maximal ankle plantar flexion, and that immobilization of the knee may not be necessary to achieve tendon-edge apposition.

Biomechanical Analysis of Dorsal Plate Fixation in Proximal Phalangeal Fractures

The biomechanical properties of three minifragment plate and screw systems were compared to determine whether plate systems primarily designed for maxillofacial reconstruction are biomechanically sound for use in proximal phalangeal fracture fixation. A middiaphyseal transverse osteotomy was created in each of 30 fresh-frozen human proximal phalanges to simulate an unstable fracture. Each osteotomy was then fixed with four 2.0ml screws through one of three different four-hole minifragment plates in a middorsal position. Plating systems tested included a vitallium plate with self-tapping screws (Luhr), a stainless steel plate with tapped screws (Synthes), and a titanium plate with tapped screws (Synthes). Testing was performed to failure in an apex volar three-point bending mode. The titanium-plated phalanges were the stiffest construct and required the greatest load and total energy absorbed to failure. However, only the load to failure for titanium versus stainless steel was significantly different. Therefore, there is no biomechanical disadvantage to using the titanium or vitallium plate and screw systems in the setting of unstable proximal phalangeal fractures.

An individualized approach to severe elbow burn contractures.

Summary: Contracture of the antecubital fossa is a common occurrence following thermal burn injury to the upper extremity. Scarring of the superficial tissues can be treated with a variety of surgical methods to provide release and coverage. However, complex scarring of the elbow, which involves the deeper structures, requires a patient-specific technique for which each scarred, shortened, or contracted component is purposefully addressed during the operation. In addition, severe elbow contractures may be complicated by other conditions, such as peripheral neuropathy and heterotopic ossification. This article will discuss the evaluation of the patient with a severe elbow burn contracture and emphasize the importance of an individualized and comprehensive surgical approach. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Correction of malunited Bennett's fracture by intra-articular osteotomy: A report of two cases

Two young male laborers had a corrective intra-articular osteotomy for a symptomatic malunited Bennetts fracture. Follow-up examination at 24 and 40 months, both patients experienced dramatic pain relief and improved thumb range of motion, and grip, and pinch strengths. A corrective intraarticular osteotomy is an acceptable alternative to arthrodesis or arthroplasy in select patients with a malunited Bennetts fracture.

Combined glenohumeral arthrodesis and above-elbow amputation for the flail limb following a complete posttraumatic brachial plexus injury.

The treatment of a severe traction injury resulting in complete, posttraumatic brachial plexus palsy remains a daunting challenge to the upper extremity surgeon. Operative intervention must address painful glenohumeral instability while optimizing functional rehabilitation. Glenohumeral arthrodesis has been shown to reliably alleviate pain from shoulder instability and place the extremity in a functional posistion for activities of daily living. An above the elbow amputation has also been advocated to remove the flail insensate extremity and create a stable stump for prosthetic training and rehabilitation. We describe the technique of a combined glenohumeral arthrodesis and above elbow amputation to address the flail insensate limb following a severe posttraumatic brachial plexus injury. In our clinical experience, the combination of procedures results in an improved pain level, enhances shoulder stability, encourages functional rehabilitation via prosthetic fitting, and is associated with high patient satisfaction.

Combined Internal and External Fixation of Complex Intra-articular Distal Radius Fractures Using Dorsal and Volar Approaches.

HISTORICAL PERSPECTIVE Most distal radius fractures are stable and amenable to closed treatment methods. However, unstable fractures with intra-articular involvement require an alternative approach. The importance of accurate restoration of the articular surface has become increasingly apparent since Knirk and Jupiter (7) first demonstrated that anatomic reduction and healing of the articular surface of the distal radius is the most critical factor for achieving a satisfactory outcome. Restoration of the distal radius can be accomplished using external or internal fixation. Both techniques are acceptable treatment approaches for specific fracture patterns (1,3-