Scott P. Steinmann

Adult traumatic brachial plexus injuries.

Abstract Adult traumatic brachial plexus injuries are devastating, and they are occurring with increasing frequency. Patient evaluation consists of a focused assessment of upper extremity sensory and motor function, radiologic studies, and, most important, preoperative and intraoperative electrodiagnostic studies. The critical concepts in surgical treatment are patient selection as well as the timing and prioritizing of restoration of function. Surgical techniques include neurolysis, nerve grafting, neurotization, and free muscle transfer. Results are variable, but increased knowledge of nerve injury and repair, as well as advances in microsurgical techniques, allow not only restoration of elbow flexion and shoulder abduction but also of useful prehension of the hand in some patients.

Stabilizing mechanism in bone-grafting of a large glenoid defect.

BACKGROUND Conventional wisdom suggests that the glenoid defect after a shoulder dislocation is anteroinferior. However, recent studies have found that the defect is located anteriorly. The purposes of this study were (1) to clarify the critical size of the anterior defect and (2) to demonstrate the stabilizing mechanism of bone-grafting. METHODS Thirteen cadaver shoulders were investigated. With use of a custom testing machine with a 50-N compression force, the peak translational force that was needed to move the humeral head and lateral humeral displacement were measured. The force was used to evaluate the joint stability. An osseous defect was created stepwise in 2-mm increments of the defect width. The bone graft was harvested from the coracoid process. The defect size was expressed as the estimated defect size divided by the measured glenoid length. Testing was performed with (1) the glenoid intact, (2) a simulated Bankart lesion, (3) the Bankart lesion repaired, (4) a 2-mm defect, (5) the Bankart lesion repaired, (6) the defect bone-grafted, (7) a 4-mm defect, (8) the Bankart lesion repaired, (9) the defect bone-grafted, (10) a 6-mm defect, (11) the Bankart lesion repaired, (12) the defect bone-grafted, (13) an 8-mm defect, (14) the Bankart lesion repaired, and (15) the defect bone-grafted. RESULTS Force and displacement decreased as the size of the osseous defect increased. The mean force after the formation of a defect of > or =6 mm (19% of the glenoid length) with the Bankart lesion repaired (22 +/- 7 N) was significantly decreased compared with the baseline force (52 +/- 11 N). Both the mean force (and standard deviation) and displacement returned to the levels of the intact condition (68 +/- 3 N and 2.6 +/- 0.4 mm, respectively) after bone-grafting (72 +/- 12 N and 2.7 +/- 0.3 mm, respectively). CONCLUSIONS An osseous defect with a width that is > or =19% of the glenoid length remains unstable even after Bankart lesion repair. The stabilizing mechanism of bone-grafting was the restoration of the glenoid concavity.

Congruent elbow plate fixation of olecranon fractures

Objectives: We hypothesize that clinical results and patient outcomes following treatment of olecranon fractures with a congruent elbow plating system will be comparable to other available plating systems. Our results will be compared to previously published reports. Design: Retrospective study. Setting: Level 1 academic referral center. Patients/Participants: The trauma registry was reviewed to identify all olecranon fractures treated with open reduction and internal fixation between January 2001 and December 2004 using the Mayo Congruent Elbow Plate system. Thirty-two patients were identified. Postoperative range of motion was initiated within 2 weeks postoperatively. Mean time to follow-up was 2.2 years (0.7-5.1). All patients had follow-up radiographs. Outcome scores were available on 24 of the 32 patients. Intervention: Medical records and radiographs of all patients were reviewed. Main Outcome Measurements: Objective measures included radiographic healing, postoperative range of motion, and complications. Subjective functional results included Mayo Elbow Performance (MEP) score; Disability of the Arm, Shoulder, and Hand (DASH) score; and patient satisfaction. Results: Of the 32 fractures, 30 went on to union. Three patients had symptomatic hardware that was removed. There was 1 infection and 1 failure of fixation also requiring hardware removal. Average arc of motion was 120 degrees. Subjective follow-up was available in 75% of patients. Mean DASH was 32. Mean MEPS was 89, with 92% good or excellent results. Conclusions: Congruent anatomic plating is a safe, effective option for the treatment of olecranon fractures with a low rate of hardware removal and stability with early motion.

Scaphoid fractures and nonunions : diagnosis and treatment

BackgroundScaphoid fractures are commonly seen in orthopedic practice. An organized and thoughtful approach to diagnosis and treatment can facilitate good outcomes. However, despite optimal treatment, complications may ensue. In the setting of nonunion or an avascular proximal pole, vascularized bone grafting may be needed.Methods and resultsIn this article we review the literature regarding these injuries and describe an approach to diagnosis, treatment, and management of scaphoid fractures and nonunions.ConclusionScaphoid fractures and nonunions may present as challenging problems in practice, but a systematic and deliberate approach can facilitate optimal results.

Axillary nerve injury: diagnosis and treatment.

Axillary nerve injury is infrequently diagnosed but is not a rare occurrence. Injury to the nerve may result from a traction force or blunt trauma applied to the shoulder. The most common zone of injury is just proximal to the quadrilateral space. Atraumatic causes of neuropathy include brachial neuritis and quadrilateral space syndrome. The vast majority of patients recover with nonoperative treatment. Baseline electromyographic and nerve conduction studies should be obtained within 4 weeks after injury, with a follow‐up evaluation at 12 weeks. If no clinical or electromyographic improvement is noted, surgery may be appropriate. The results of operative repair are best if surgery is performed within 3 to 6 months from the injury. Surgical options include neurolysis, nerve grafting, and neurotization. The results of repair of axillary nerve injuries have been good compared with treatment of other peripheral nerve lesions, due to the monofascicular composition of the nerve and the relatively short distance between the zone of injury and the motor end‐plate.

Precontoured Parallel Plate Fixation of AO/OTA Type C Distal Humerus Fractures

Objectives: To determine the clinical effectiveness of precontoured parallel plating for the management of Orthopaedic Trauma Association (OTA) type C distal humerus fractures. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Between 2001 and 2005, 37 patients with OTA type C distal humerus fractures underwent open reduction and internal fixation exclusively with the Mayo Elbow Congruent Plating system. Thirty-two patients consented to participate in the study. Intervention: All patients underwent open reduction and internal fixation with a precontoured bicolumn parallel plating system. Main Outcome Measurements: Range of motion, Mayo Elbow Performance Score, Disabilities of the Arm, Shoulder and Hand score (DASH), complication rate, and radiographic evaluation. Results: At a mean of 27 months follow up, the mean arc of elbow flexion-extension motion was 97° (range, 10°-145°). The mean Mayo Elbow Performance Score was 82 points and the mean DASH score was 24 points. There were no implant failures and all distal humerus fractures healed. A total of 24 complications occurred in 17 patients (53%) with five patients (16%) having postoperative nerve injuries. Conclusions: Open reduction and internal fixation with a precontoured parallel plating system is an effective treatment method for OTA type C distal humerus fractures. Despite this, the fact that over half of the patients had a significant complication will require utmost vigilance on the part of the surgeon to avoid intraoperative complications. Patient counseling is paramount.

Arthroscopic Treatment of the Arthritic Elbow

Elbow arthroscopy is now being used with greater frequency to treat arthritis and contractures. The procedure is technically demanding and the potential for injury to neurovascular structures remains a concern. Potential advantages of arthroscopic treatment include improved articular visualization and decreased postoperative pain. Patients may also benefit from decreased morbidity and a faster postoperative recovery. Elbow arthroscopy can be performed for removal of loose bodies, resection of symptomatic plica, release of the capsule in patients with contracture, removal of osteophytes, treatment of synovectomy in inflammatory arthritis, treatment of osteochondritis dissecans, débridement of lateral epicondylitis, and treatment of elbow fractures.

Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision

The purpose of this study was to describe a novel technique for repair of partial distal biceps tendon ruptures through a single posterior incision. Eight patients with partial distal biceps tendon ruptures had the tear confirmed and repaired through a single posterior incision. All were men. The mean age was 50 years (range, 36-60 years). Postoperatively, immediate active and passive motion was instituted. Seven of eight patients returned to their previous professions. The mean postoperative American Shoulder and Elbow Surgeons elbow score was 96 (range, 89-100). Six of the patients were completely satisfied, and all were much improved. There were no complications. Surgical confirmation and repair of symptomatic partial distal biceps tendon ruptures can be performed through a single posterior incision. The morbidity of the anterior exposure can be avoided and the tendon readily explored and reattached with excellent patient outcomes. The security of repairing the tendon directly into a trough in bone and suturing over cortical bone permits immediate rehabilitation without immobilization in a cast or splint.

Immediate Active Range of Motion After Modified 2-Incision Repair in Acute Distal Biceps Tendon Rupture

Background Different rehabilitation protocols have been used after repair of distal biceps ruptures. Purpose This study investigates the safety of immediate active range of motion protocol after modified 2-incision distal biceps tendon repair in acute ruptures. Study Design Case series; Level of evidence, 4. Materials and Methods Twenty-one patients with a minimum follow-up of 2 years were participants in this study. After repair, the upper extremities were placed in a sling for 1 to 2 days and then immediate active range of motion was started. For the first 6 weeks, the elbow was allowed activities of daily living as tolerated by the patient with a 1-lb weight-lifting restriction. Elbow range of motion, isometric and dynamic flexion, and supination strengths were recorded and Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained. Results Mean follow-up extension was 0° and mean follow-up flexion was 141° on the operated side, with supination of 74° and pronation of 75°. The mean DASH score for 21 patients was 3.6 ± 3.6 (range, 0-11.4). The mean follow-up isometric flexion strength was found to be 5% (P = .411), and the power (dynamic strength) of flexion was 12% greater on the operated side (P = .046). However, follow-up isometric supination strength was 9% less on the involved side than on the noninvolved side (P = .030), and the power of supination was 11% less on the operated side (P = .007). There were no tendon reruptures at follow-up, determined by physical examination. Conclusion A modified 2-incision distal biceps repair allows a safe immediate active range of motion protocol with early return of nearly full range of motion and strength, without any clinically significant disability.

Treatment of periprosthetic humerus fractures associated with shoulder arthroplasty.

Abstract The incidence of periprosthetic humerus fracture associated with shoulder arthroplasty is approximately 0.6% to 3%. Fractures of the humerus occur most often intraoperatively and are more common during total shoulder arthroplasty than hemiarthroplasty because of difficulties in gaining access to the glenoid. Osteopenia, advanced age, female sex, and rheumatoid arthritis are medical comorbid factors that may contribute to humerus fractures and associated delayed healing and poorer function. When the humeral prosthetic component is loose or the fracture line overlaps the majority of the length of the prosthesis, revision with a long‐stem implant should be considered. When the fracture overlaps the tip of the prosthesis and extends distally, open reduction and internal fixation is recommended. When the fracture is completely distal to the prosthesis and satisfactory alignment at the fracture site can be maintained with a fracture brace, then a trial of nonsurgical treatment is recommended. The primary goals of treatment are fracture union and pain relief. Loss of glenohumeral motion has limited the successful treatment of this challenging problem.