Seth D. Dodds

Perinatal brachial plexus palsy.

Perinatal brachial plexus palsy (PBPP) has been traditionally classified into three types: upper plexus palsy (Erbs) affecting the C5, C6, and +/- C7 nerve roots, lower plexus palsy (Klumpkes) affecting the C8 and T1 nerve roots, and total plexus palsy. Although most cases will resolve spontaneously, the natural history of the remaining cases is influenced by contractures of uninvolved muscle groups and subluxation or dislocation of the shoulder and elbow. Microsurgical nerve repair has demonstrated to provide improved outcomes compared to conservative treatment, while advancements in secondary reconstruction have offered significant improvements in the performance of activities of daily living for older children with unresolved plexus palsy.

Trigger finger: etiology, evaluation, and treatment.

Trigger finger is a common finger aliment, thought to be caused by inflammation and subsequent narrowing of the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. Although it can occur in anyone, it is seen more frequently in the diabetic population and in women, typically in the fifth to sixth decade of life. The diagnosis is usually fairly straightforward, as most patients complain of clicking or locking of the finger, but other pathological processes such as fracture, tumor, or other traumatic soft tissue injuries must be excluded. Treatment modalities, including splinting, corticosteroid injection, or surgical release, are very effective and are tailored to the severity and duration of symptoms.

Surgical treatment of distal biceps rupture.

Rupture of the distal biceps tendon accounts for 10% of all biceps brachii ruptures. Injuries typically occur in the dominant elbow of men aged 40 to 49 years during eccentric contraction of the biceps. Degenerative changes, decreased vascularity, and tendon impingement may precede rupture. Although nonsurgical management is an option, healthy, active persons with distal biceps tendon ruptures benefit from early surgical repair, gaining improved strength in forearm supination and, to a lesser degree, elbow flexion. Biomechanical studies have tested the strength and displacement of various repairs; the suspensory cortical button technique exhibits maximum peak load to failure in vitro, and suture anchor and interosseous screw techniques yield the least displacement. Surgical complications include sensory and motor neurapraxia, infection, and heterotopic ossification. Current trends in postoperative rehabilitation include an early return to motion and to activities of daily living.

Distal triceps rupture.

Distal triceps rupture is an uncommon injury. It is most often associated with anabolic steroid use, weight lifting, and laceration. Other local and systemic risk factors include local steroid injection, olecranon bursitis, and hyperparathyroidism. Distal triceps rupture is usually caused by a fall on an outstretched hand or a direct blow. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may limit the ability to evaluate strength and elbow range of motion. Although plain radiographs are helpful in ruling out other elbow pathology, MRI is used to confirm the diagnosis, classify the injury, and guide management. Incomplete tears with active elbow extension against resistance are managed nonsurgically. Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength. Good to excellent results have been reported with surgical repair, and very good results have been achieved even for chronic tears.

Essex-Lopresti Injuries

The Essex-Lopresti injury results from a high energy trauma to the upper extremity causing significant instability to the forearm joint. The radial head is fractured, the interosseous membrane is torn, and the distal radioulnar joint is disrupted. Frequently, the greatest challenge with this specific injury pattern is the diagnosis, because it is often missed in the emergency room. Once the diagnosis has been established, surgical treatment focuses on the elbow (radial head fracture) and the wrist (distal radioulnar joint disruption) to restore forearm length and stability. Chronic or untreated Essex-Lopresti lesions continue to challenge treating physicians and often require salvage or reconstructive procedures to minimize pain and return function.

Terrible triad of the elbow.

The terrible triad of the elbow is a difficult injury with historically poor outcomes. Improved experience, techniques, and implants have advanced to the point where restoration of elbow stability can be expected. Careful attention to each destabilizing element of the injury pattern is essential and places high demands on the surgeons mastery of the anatomic complexity of the elbow. Technically, the surgeon must bring every skill to bear, as soft tissue techniques, fracture repair, and joint arthroplasty are routinely required to adequately treat these complex constellations of injury.

Non-operative treatment of common finger injuries

Finger fractures are common injuries with a wide spectrum of presentation. Although a vast majority of these injuries may be treated non-operatively with gentle reduction, appropriate splinting, and careful follow-up, health care providers must recognize injury patterns that require more specialized care. Injuries involving unstable fracture patterns, intra-articular extension, or tendon function tend to have suboptimal outcomes with non-operative treatment. Other injuries including terminal extensor tendon injuries (mallet finger), stable non-articular fractures, and distal phalanx tuft fractures are readily treated by conservative means, and in general do quite well. Appropriate understanding of finger fracture patterns, treatment modalities, and injuries requiring referral is critical for optimal patient outcomes.

Injuries to the Pectoralis Major

AbstractPectoralis major injuries typically occur in active individuals participating in manual labour or sports. While these injuries are rarely reported, the actual incidence of pectoralis tears among all shoulder injuries is unknown. Diagnosis can usually be made based on a patient’s history and physical examination. However, ultrasound and magnetic resonance imaging are helpful tools for diagnosis and pre-operative planning. Specific treatment options should be based on the severity of the injury and the patient’s individual needs. Nonoperative management consisting of immobilisation and physical therapy can offer a functional result with return of shoulder motion and activities of daily living. In recent studies, operative repair of pectoralis major rupture has been shown to restore normal chest-wall muscle contours and pre-operative strength (even in competitive athletes). Although complications such as re-rupture, infection, and heterotopic ossification do occasionally occur, favourable results should be expected when surgical repair is performed either acutely or in a delayed fashion.

Assessment of scaphoid fracture healing.

Scaphoid fractures are among the most common hand fractures in adults. The geometry of the scaphoid as it relates to its retrograde blood supply renders it particularly prone to avascular necrosis and other fracture complications. Though there has been long-standing debate over the optimal method of diagnosing scaphoid fractures, the best and most cost-effective methods combine clinical exam with other imaging modalities such as navicular view plain films, CT, and MRI for particularly questionable presentations. Once a scaphoid fracture is diagnosed, it should be followed by an orthopaedic surgeon and treated with cast immobilization or operative management in the case of displaced fractures. Fractures should be followed to monitor healing progress in order to ensure the eventual development of bridging bone across the fracture line, usually best appreciated on CT. Proper treatment of scaphoid fractures and assessment of fracture healing can minimize the occurrence of non-unions and associated arthritic changes.

Single and incremental trauma models: a biomechanical assessment of spinal instability.

Abstract. Biomechanical analysis of spinal injury in the laboratory requires the development of trauma models that simulate spinal instability. Current experimental trauma protocols consist of two types: single or incremental impacts. The incremental protocol has several advantages. However, the equivalence of the spinal instabilities produced by the two trauma protocols is currently unproven. The purpose of this study was to investigate whether the single and incremental trauma models produce equivalent soft tissue instabilities in the lumbar spine. Ten freshly frozen porcine lumbar spines were divided into two functional spinal units (FSUs), L2-L3 and L4-L5. FSUs were then randomized to either the single trauma (ST) or incremental trauma (IT) protocol. The IT protocol consisted of four sequentially increasing high-speed axial compression traumas, while the ST protocol was a single impact of the same magnitude as the final trauma of the IT. Before and after the final trauma, each FSU underwent flexibility testing under flexion/extension, lateral bending, and axial torsion pure moments. No significant differences were found in neutral zone or range of motion between IT and ST specimens in any of the three axes of motion, either before or after the trauma. In addition, no differences were found between the normalized motions of the IT and ST groups. The FSUs subjected to incremental trauma do not suffer greater injury than those subjected to a single impact. The data support the equivalency of the subfailure soft tissue injuries of the spine caused by the incremental and single trauma protocols respectively. This finding is important, because only with the incremental trauma protocol is one able to obtain injury threshold, study injury progression in the same specimen, produce a defined injury more accurately, and efficiently utilize scarce human cadaveric specimens.